“Sustainable” is an adjective that gets thrown around a lot in virtually any debate.  It’s almost always in response to the affordability question and the answer is almost always in the negative, as in, “This program in unsustainable.”

But sustainability isn’t a bottom line – it’s a choice.  It’s the small choices a person makes about what to eat, what to wear and where to go on weekends.  It’s the much more significant and long-term choices we make about the work we do, where we live, what we drive and where we send our children to college.  It’s about our habits, goals and priorities.

In the same way, sustainability is addressed at the community level.  Not everything a community chooses to do (through its duly elected representatives) pays for itself – far from it.  Public transportation, recreation, security and human services that could never stand on their own are implemented and subsidized with public funds.

The same thing happens at the state and national level, only with much greater sums and, it seems, much less empathy as the distance from taxpayer and beneficiary to policymaker grows.  But, again, it is about priorities driving choices, choices driving investment and investment creating value.

Much of the argument against Medicaid expansion hinges on its alleged sustainability with regard to its reliance on federal funding.  Of course, right from the starting line the wheels begin to fall off that argument once the opponent is confronted with the reality that (1) expansion is paid for through the existing taxing and fee provisions of the Affordable Care Act and (2) the majority of funding for the governor’s alternative plan comes from Washington, D.C.

So it’s really not about sustainability; it is about priority and will.  For the last several decades, the federal government and presidential administrations from both major parties have willingly made Medicaid a priority and supported it as such.  This is consistent with the general will of voters, who desire to assist our most vulnerable citizens with the most basic needs, from food and shelter to transportation and education.  And yet for some, suddenly, it’s become debatable whether or not health care belongs on that list.

You don’t have to be a health care provider to find that absurd, but it seems providers are still needed to remind policymakers that health is the bedrock supporting the foundation of society.  What good is education for a child who is too sick to attend class?  What good is economic development to someone who can’t stay well enough, long enough to keep a job?

There are too many Iowans who lack access to health care because they are uninsured – that much of this debate is all but settled.  The unsettled question is how do we change that.  The governor advocates a plan that is overly limited in terms of the people it assists, the providers they can use and the services they can receive.

Proponents of this plan cloud these shortcomings with talk about patient buy-in, coordinated care and incentives for wellness and outcomes, as if Iowa health care providers had never heard of such things or could not manage their implementation without government involvement.  Iowa hospitals’ priority to ensure high-quality, patient-centered care, address overall health and control costs predate the fresh-from-the-oven (though not yet fully baked) Healthy Iowa Plan by years, if not decades.  That the “Triple Aim” has suddenly penetrated the thick walls of the Statehouse is to providers’ credit.

But what providers do and what legislators now realize about the Triple Aim matters little to low-income Iowans who are not engaged with the health care system.  Innovation becomes meaningless when basic access is denied.  Legislators need reminding that providing access is not so much a matter of dollars, but of remembering our Iowa priorities and mustering the will to sustain them.

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The following is testimony regarding Medicaid Expansion provided to Iowa legislators by Dr. Richard Deming, medical director of Mercy Cancer Center in Des Moines and president of the Mercy Medical Center medical staff.

I read with great interest Governor Branstad’s op-ed piece in the Des Moines Register describing his Healthy Iowa plan.  I appreciate that he quoted President Obama regarding health care reform and cost control.  I appreciate the governor’s concerns about the inadequacies of Medicaid.  I agree that Medicaid is far from a perfect program and is in need of improvement.

I applaud Governor Branstad’s efforts to develop “an improved health care program for the neediest Iowans.”  I agree with health care reform.  I am in favor of personal responsibility and accountability.  I am here to tell you that I would like to work with the governor and the state Legislature to help achieve this.

I am also here to speak in favor of Medicaid expansion.  My remarks this evening will fall into three categories: passion, practicality and compromise.

First, passion.  It’s all about access.  I’m in favor of patient accountability, but before we can have accountability, we need access.  Without access, there is no opportunity for accountability.

Each and every day I see individuals who do not have insurance who present with advanced cancer because they put off seeking medical attention until it’s too late. Without access, individuals do not get preventive services, do not get early detection screenings and do not obtain services when cancer is in an early stage.

Eventually they become ill as their cancer progresses and eventually they ask for help and eventually they come to see me with advanced cancer.  At that point, it’s often too late to be able to cure their cancer.

For me, this debate is not primarily about the finances and it’s certainly not about my pocketbook.  It’s about human dignity and social justice.  I have never ever turned down a patient because he or she wasn’t able to pay.  I never will, regardless of how this vote goes.

But if individuals don’t have access, they won’t attempt to obtain prevention and early detection.  They will come to me for free care when I can no longer cure them of their cancer because it is too advanced.

Second, practicality.  I truly believe that expanding Medicaid will be the most economical way for our state to provide health insurance to the most vulnerable.  Many of the other speakers this evening have covered the financial concerns, so I won’t elaborate.  I believe the Medicaid expansion bill will provide more coverage for more Iowans at considerable less expensive to the state than the governor’s Healthy Iowa Plan.

One aspect of the financial debate that I haven’t heard articulated is the fact that, as a result of the Affordable Care Act, in anticipation of the federal funding of Medicaid expansion, Medicare is withholding from Iowa hospitals 2 percent of the funding they should be receiving.  This amounts to $178 million a year.  For Mercy-Des Moines, it’s about $18 million a year.

That is money that is being held in Washington to pay for Medicaid expansion.  If we turn down Medicaid expansion, we will be left in the unthinkable situation of having “forfeited” $178 million and then using Iowa property tax revenues to pay for the Healthy Iowa Plan.  From a practical point of view, we need to accept the federal dollars and expand Medicaid.

Third, compromise.  I agree with the governor that we need to reform health care and make it more accountable.  We at Mercy are “all in” when it comes to accountable care.  We have already developed an accountable care plan for our own employees.  We have developed an accountable care plan for our Medicare patients and we have developed an accountable care plan for a segment of our privately insured patients.  We have already had a meeting with the Medicaid office to discuss developing accountable care around Medicaid.

Iowa needs to work with the federal government to develop a plan to provide accountable care for the Medicaid population. But this can be done through Medicaid expansion.

Governor Branstad and Iowa legislators, I promise you this:

If we expand Medicaid, Mercy will work with you and the Medicaid program to help develop a system of accountable care for Medicaid patients.  I will personally work with you to help bring health systems and physicians to the table to work on an innovative way for Iowa to create accountable care for our Medicaid enrollees.  As I said, we are already doing it for Medicare, we are doing it for our employees, we are doing it for some of our privately insured – and we can do it for Medicaid.

Cancer, health and well-being are not the domains of any one political party.

The Dalai Lama said, “My religion is compassion.”  I agree.  I’d also say, “My politics is compassion.”  I realize that one can spoil a child if one’s compassion becomes smothering without an attempt at discipline.  But I also understand that without compassion, children will not have the opportunity to thrive.

I agree with the need for both compassion and accountability.  But before we can have accountability we need access.  Without access, there is no opportunity for accountability.

Thank you for allowing me to speak to you this evening.

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The Iowa Legislature is heading down the stretch toward an historic opportunity to greatly improve the well-being of Iowans by providing comprehensive insurance to 150,000 citizens who currently lack coverage.  In pursuing this goal, policymakers should be aware of the following facts concerning Iowa’s Medicaid program.

First, similar to every other state’s current program, Iowa spends two-thirds of its Medicaid dollars on severely, chronically disabled individuals who make up approximately one-third of the  Medicaid population.  These individuals include those who through no fault of their own have health issues that correlate to developmental disabilities or mental illness.

These are individuals who are dependent upon access to health care to lead a productive life.  A productive life ranges from simply being part of a family to contributing economically to our society by holding a job and all that goes with it.  The medical services to support these individuals are often high-cost, but the return to society in the form of value we place upon each and every life speaks volumes about Iowa.

Second, again like every other state, Iowa spends one-third of its Medicaid money on two-thirds of the individuals in the program, predominantly mothers and children.  This is not a high-cost population as most of the care delivered relates to pregnancies and keeping children healthy.  Insuring children in low-income households has helped them remain healthy and stay in school.  For similar reasons, it makes sense to insure their parents as well.

Third, Medicaid isn’t broken; it operates exactly the way it was designed to operate and Legislatures and governors are the chief architects.  As a state-federal partnership, the state controls access to the scope of care provided as long as physician and hospital services are included, which is the fundamental mandate of Medicaid.

Although changes to this partnership require federal approval, Health and Human Services (HHS) Secretary Kathleen Sebelius has personally pledged to Iowa policymakers and private citizens her desire to work collaboratively to construct innovative responses to management of Medicaid.  This requires proactive engagement and communication with HHS, not reactive filings of Medicaid waivers with known problems.

Since FY 2000, there have been 14 expansions of Iowa Medicaid that include both services and eligibility.  Because of this legislative action, Medicaid enrollment has increased by 92 percent and the cost per recipient has increased 64 percent.  These numbers are inclusive of programs like HAWK-I and IowaCare.  Contrast these numbers to Iowa’s spending on just K-12 education, where enrollment has dropped by 3.5 percent while per-pupil expenditures have risen 61.9 percent over the same time period.

Fourth, Medicaid is entirely sustainable.  Most of the concepts for system and payment reform embodied in the national health care reform law are either being actively pursued by Iowa’s Medicaid program or are in proposals before the Legislature, including the governor’s proposal.  Hospitals support these system and payment reform proposals; the predominant argument in the Legislature today is over whether to take federal money already allocated for Iowa.

Fifth, Medicaid expansion is the single biggest economic development idea to present itself to our state in at least the past 25 years.  It will create in excess of 2,000 jobs while bringing in an average of $313 million dollars to Iowa on an annual basis.  On top of that, businesses that employ uninsured working Iowans will be relieved of annual taxes in the amount of $20 million dollars to the federal government while their employees get coverage.  Additionally, county governments will save up to $60 million dollars annually in mental health care costs.

Policymakers are elected to represent all Iowans, not just those who have access to health insurance.  It’s time for our policymakers to recognize the wide expanse of common ground available in restructuring Medicaid and accept all of the federal support offered to our state.  That way, Iowa can have a serious shot at becoming the healthiest state in the nation.

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Recent communications from opponents of Medicaid expansion, including items published in newspapers, have included confusing and misleading information.  These statements have generally fallen into two broad areas: the growth of Medicaid and the quality of care provided to Medicaid beneficiaries.

In newsletter articles to constituents as well as newspaper columns, expansion opponents in the Legislature have noted that Medicaid enrollment in Iowa has risen substantially since 2000.  This is true, of course, and for a number of reasons, not the least of which are more than a dozen policy decisions made by legislators which added more than 80,000 people to the Medicaid rolls, as well as the economic downturn – the worst since the Great Depression – which saw tens of thousands of Iowans lose their health insurance.

Opponents have also pointed out that there are as many as 81,000 people in Iowa who are eligible for Medicaid but not now enrolled.  They postulate that the publicity surrounding Medicaid expansion will encourage these Iowans to sign up for the program and drive up costs.

This is a real possibility, but it’s just as likely (if not more) that those people will “come out of the woodwork” when the individual health insurance mandate and health benefit exchanges begin in 2014.  Therefore, it makes more sense to attribute any increase to health benefit exchanges – which Iowa is now pursuing – than to expanding health insurance to an entirely new population.  It’s misleading for opponents to attribute these costs to Medicaid expansion when the state obligated itself to provide coverage to these individuals long before expansion was an issue.

No one is claiming that expansion is “free,” certainly not hospitals, which are taking billions of dollars in Medicare cuts to help finance it.  But let’s keep front and center the benefits of expansion (in addition to providing coverage to tens of thousands of Iowans and, speaking of care that isn’t free, reducing Iowa hospitals’ $1 billion in yearly uncompensated care).

The fact is the Kaiser Family Foundation, a nationally recognized nonpartisan research center, released a report in November 2012 examining the impact of expanding Medicaid on state governments.  Specifically, the Kaiser report indicated that expanding Medicaid in Iowa could save our state as much as $30 million annually in reduced costs in other areas.  Furthermore, the Iowa Medicaid program found in its research that expansion will save as much as $60 million in county property taxes for mental health services.  Additionally, independent research has shown Medicaid expansion will inject $2.2 billion into the Iowa economy and add more than 2,300 jobs across the state.

Finally, without providing any details, sources or studies, several legislators are claiming that current Iowa Medicaid recipients “are not getting any healthier.”  This flies in the face of well-documented evidence showing Iowans – all Iowans – receive some of the highest quality care in the nation.

Such statements are also an affront to Iowa hospitals, physicians and other health care professionals who are committed to continuous improvement through efforts like Partnership for Patients and the ongoing work of the Iowa Healthcare Collaborative.  Hospital advocates should not sit still for this and be quick to point out the resources that have been committed, the progress being made and the recognitions achieved because of their hospitals’ dedication to high-value, highly-coordinated, patient-centered health care.

Iowa already has an excellent health care system that is always challenging itself to get even better.  But Iowans cannot fully benefit from the system without insurance.  Medicaid expansion remains Iowa’s best opportunity to provide coverage and improved access to health care for as many as 150,000 uninsured, low-income Iowans.

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Here in Iowa and across the nation, arguments for Medicaid expansion have weighed heavily on those who have taken the opposite stand.  The problem for them is the facts keep getting in the way of their rhetoric.

IHA’s media campaign is flooding the radio waves and providing persuasive video presentations to listeners and viewers across the state.  These carefully crafted messages are making the expansion argument point-by-point, showing how expansion will benefit individual Iowans and improve mental health access, for example.  The videos also make the business case for expansion and dispel the myths that have been propagated by opponents.

Meanwhile, independent research is providing further evidence to support the hospital position.  A report from George Washington University shows expansion will bring nearly $2.2 billion to the state and create as many as 2,362 jobs – more than 14 times the jobs promised by the widely heralded state economic development project in Southeast Iowa.

Research has also shown that a solid majority of Iowans back expansion in all parts of the state.  Those same Iowans overwhelmingly want to ensure that their neighbors have access to preventive and mental health care, so when they realize expansion provides exactly that, they are even more supportive.  And when they learn of the economic benefits, their support becomes even greater.

Such mounting evidence has been very persuasive to newspaper editorial boards across the state.  Practically every major Iowa daily newspaper has endorsed IHA’s position, from Council Bluffs to Des Moines to the Quad Cities – and back again to Iowa City (including the university’s newspaper), Cedar Rapids, Mason City and, most recently, Sioux City.  At the same time, hospital leaders have stepped forward to amplify and localize the case for expansion (examples here, here and here.)

There is still much work to be done.  The Iowa business community has been, for the most part, noncommittal on the question, even as the business, economic impact and popular opinion data have clearly favored expansion.

More evidence came to light recently as an analysis showed $17 billion in federal Disproportionate Share Hospital funding will be cut, with the expectation that Medicaid expansion would cover the difference.  For states that don’t expand?  Well, that’s just another hit (along with exploding uncompensated care) that private payers (meaning employers) will have to help offset.

Also this week, Jackson Hewitt Tax Service reported that Iowa’s failure to accept expansion would cost state businesses between $12.7 and $19.1 million a year in “shared responsibility” penalty payments related to uninsured Iowans seeking coverage through the state’s insurance exchange.  Bottom line: “State government efforts to constrain Medicaid costs growth in and after 2017 may lead to higher net taxes for employers…beginning in 2014.”

Meanwhile, another analysis shows Medicaid expansion will benefit our military veterans.

These are the pro-expansion realities that eclipse the oppositional rhetoric.  These are the facts that bear repeating to legislators and locals because understanding has done nothing but nurture support.

Medicaid expansion remains a win-win-win for Iowans, Iowa government and Iowa businesses.  But the argument will not be won until everyone understands just how much is at stake.

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