Investing in a healthier, skilled workforce?


As many of you know…I am drawn to the story of the un-insured here in South Carolina. Each person I meet, each interview I sit through, each image I capture…I am reminded where I was a few years ago.

There is a massive, polarizing conversation right now surrounding health care, access to care, and american rights vs/ patient rights. The one area that has me most sympathetic are those who are struggling each day to pay the rent, pay to put clothes on their children’s backs, work, and have access to quality health care.

When I attended the SC Mission 2013 Lowcountry event in Charleston, SC…I was reminded how many people are struggling to find not only basic services but specialized services. I met and individual who traveled four hours from Anderson, SC to Charleston, SC to spend the night outside so he and his wife could be one of the first in line to receive care.

I sometimes worry about sharing these stories, worry about the implications for this advocacy, worry about the impact it could have on my business. I am a small business supported by large health care systems, large advocacy groups, large endowments, large heath insurance providers, economic development organizations who all have a different perspective on this growing problem.

The stories of the uninsured are overwhelming and sometimes under reported. What I mean…we often here more of the public policy conversation surrounding their stories and less about their needs. What I have found…most of the individuals that are attending these large free medical clinics are searching for care because of their situation. They are either recently unemployed, unable to afford private insurance, young adults fresh out of college working part time, and/or older adults who have lost jobs who do not have enough income for additional insurance beyond Medicare.

For past several years, I have documenting the stories of the uninsured. I have been interview the people that live in the margins. I hear their stories and I many times I see myself on the other side of these interviews. At one time, Sarah and I were uninsured after leaving a business that was slowly declining after the 2008 economic downfall. There were not many jobs, so I decided to workforce for myself and after a year of working hard…we were finally able to afford private insurance.

We were making the same decisions. Should we path mortgage, go to the grocery store, afford the essentials or try to find provide health insurance. Did you notice we did not consider health insurance an essential line item in the budget. So…if I had a car wreck, or life threatening incident…who would cover that cost? Should the hospital bear that burden? Would I receive the care and go bankrupt?

In 2013, our healthcare insurance premium was roughly $560.00 month for our family of three. We had a high deductible policy with an HSA plan where we invest $400.00 month. That is almost $1000.00 per month in health coverage. WOW…that is a lot of money. When I was self-employed, I found ways to make this a tax deductible expense since I…but the at is a large outflow of cash each month. Now, I have my health insurance through our company’s group plan which is roughly $1100 per month. A lot of money for a family who is relatively healthy.

So when I sit in a public policy meeting and my local state representative says that Republicans in SC will not let it pass…I wonder, has she met these individuals who are making choices like we made? Has she met the individuals across to the state who are going to extreme measures to attend free-medical clinics.

Yes…I look around the room when I speak up in these public policy meetings. I see people writing notes when I advocate and speak for the uninsured. I wonder…do they know what it is like to wonder how to filth at prescription, or get scared when they get sick with bronchitis with no access to quality care.

bobby-healthyinvestment-blog3After interviewing Bill Settlemeyer in 2013, I shared similar same questions. Mr. Settlemeyer, a business man in Charleston, SC, asks…”why don’t our elected leadership who oppose the Medicaid Expansion or ACA give up their insurance if they feel it is not important.” I agree.

My mother sees a whole different perspective. She has been a nurse for a major health care system for over 20 years . She works I the Emergency Department as a Nurse Practitioner and has seen first hand the impact of there current Medicaid system. Each day she has a patient who is leveraging the system, many with expensive cars, lots of gadgets, highly intoxicated on more than alcohol demanding services or they will scream. Yes…literally scream or complain. These repeat offenders abusing the current system with no problem how the financial obligation is resolved…as long as they get their prescription drugs they demand.

She takes care of the poor, those in need. She even puts money in the pockets of those who really need help and needs a cab ride home or a hot meal. She is sympathetic to those in need yet overwhelmed by those who abuse resources meant to care for the needy.

We have seen the Facebook memes that share my mom’s frustrations. You know the doctor’s telling the stories of those who abuse the system in Emergency Departments across the US. They are overworked an overwhelmed by the many who leverage the resources of small/medium/large hospitals at the expense of those who need the care.

My mom and I debate the ACA and the Medicaid Expansion. She is not alone…more and more medical providers I meet, the more they question the implementation of these policy decisions.

So what is Affordable Care? I ask this question many times…what is it? I remember when our daughter fractured her leg. She had just learned to walk and one of her cousins feel on her leg giving her a green stick fracture. We found ourselves in the orthopedic doctors office getting a cast before Christmas. It was not until the final visit did we actually learn the total bill for all the services, visits, casts, x-rays, and other little expenses.

We were sitting I the cast room and they asked if we wanted a special color cast or just a regular cast. At no time did cost come into the discussion when choosing pink over plain. I have no idea if it cost more or not. In these weeks to follow, a new bill would show up. $200.00 here, $300.00 there, and before you know it…we accumulated close to $1500.00 in medial bills. Now…I would have paid for it or found a way to pay for those services. But…why it is this a reactionary practice?

What do I mean by a reactionary practice. We were not able to plan for this un-planned expenses. We have an emergency fund in our budget and our HSA account was prepared. But at no point were we able to make any decisions based on costs. We had to sit back, bite our fingernails and wait for the looming bills to arrive.

For a family on a tight, single income budget…every dollar is important. Would it have been cheaper to get the x-ray at a different office? Would it have been cheaper to ask for the plain cast? Would it have been cheaper to go the Emergency Room instead of the doctor’s office? I have no answered because we had no idea of costs associated do these services until afterwards.

Now I understand the ethical balance here. Should we be making health care choices based solely on costs? Would it be the same quality care? And here is the big one…why do the health insurance providers get to negotiate costs without consulting those who are impacted by the services provided?

Recently in South Carolina, policy makers and the public have been pushing hospitals to release the document that ultimately decides the costs associated with services. This is called the charge master. This is the magic “document” that each hospital uses to determine costs for each service provided. So the cost of one service at one hospital might be different at another hospital around the corner…for that same service. This is based on how their charge master determines the costs when it factors all the variables ranging from insurance contacts, physician contracts, subsidies and reimbursements from the state and federal government, and numerous others that I do not understand.

So…how do insurance companies determine how much they reimburse for each service (transaction) that pay out to the provider. If I broke a bone in my leg, needed surgery, need physical therapy, and other services…would it be the same payout if my brother-in-law had the same occurrence with the same insurance provider and similar policy? I don’t know….but probably not since his health insurance provider negotiated a different rate than my health insurance provider.

Based on these questions and many other factors, SC now has a portal for individuals to compare costs, it is called You can now compare costs between hospitals for services ranging from hip-replacement, heart surgery, and so much more. Consumerism is forcing hospitals to disclose costs pushing us further into the consumer based model. But…there is a long road ahead.

One of my former clients is part of a large health insurance company. Well, they are not an insurance company, they are a transaction company. Yes…their business model is determined how by many transactions their mainframes can execute. So let’s talk about this a little bit.

BCBS of SC is an Information Technology (IT) company. Yes, they process transactions on their mainframes that run a programming language called COBOL. This is an older programming language that is loosing the needed skilled workforce needed to keep these mainframes running. Many of the baby boomers running mainframes are retiring with no one to replace them.

There is movement across the country to attract a new pipeline of talent to run company like BCBS, IBM, and many other large computing companies that use large mainframes. They are influencing the educational movement to create new higher education programs to train the. Next wave of IT professionals. They are reaching out to the K-12 schools to empower youth that IT is cool, not just for geeks.

There is a need for more people to support groups like BCBS to continue to execute transactions because health care has become an interconnected, digital paradigm necessary for health care to operate. We are creating more transactions. Our transactions are each time we get sick, each time we go to the emergency room, each time we need a prescription, each time we have a car wreck.

We rely on these transactions. Our medical records are now following USC rom hospital to hospital, from clinic to clinic, from physician practice to specialty practice. Each medical record across the digital health care system transacts wig a different program. From hospital to free medical clinic, each one has a different system connected by large computing companies that depend on making that transaction happen.

Health care is now about transactions. I recently worked with SC DHHS as they created a new system called SCHIEX. A backend computing system that connects her he medical record systems across the state of SC. This is exciting because we can now access one’s medical records from the ambulance before we get even get to the hospital. This massive infrastructure is connecting providers to patients.

This infrastructure comes at a cost. Small physician practices no longer can stand the massive overhead necessary to compete. The days of small practices are slowly drifting as we are seeing more and more large hospitals purchasing physician practices. Why, because the small practices can no longer afford the increasing costs of maintaining necessary infrastructure like EMR/HMR’s, negotiating with insurance providers, managing billing, malpractice insurance, etc. It is just getting harder and harder to run a small doctors office.

And when the large system’s partner or buy them out…they have to keep up the pace of managing a large business run machine. It is all about transactions. It is all about the number of patients each day coming in and out of the practice.

A closer college buddy had a dream of practicing medicine with his mentor in Clemson, SC. He joined the practice in the hopes of integrating himself in the community. The practice eventually was sold to a large health care system and the pace was unbearable. No time to spend with patients and the reality of the quota system drove him away. He started a concierge practice to spend more time with the patient, the paying patient. The price for his services…a yearly fee paid in cash and you get complete access to him. Great business…but what about the people who cannot afford that large yearly lump sum of money.

The divide is getting bigger and bigger because more and more doctors are getting away from patient centered care and into the business model of transactional health care. Some are finding ways around this problem.

I met a wonderful pediatrician, Dr. Wendy Sue Swanson or Seattle Mama Doc, from Seattle Children’s Hospital who was getting tired of only spending 15 minutes in the exam rooms with the patient and their family members. She told me she had an Ivy League education yet did not have time to empower people with her knowledge. So she started a blog dedicated to the information she could not share in the exam room.

Now she is the go to person for anything pediatric. If you have a question about the latest research, latest child car seat, flu shots, or concerned about raising an infant, she is the person who shows up in the search engines. She is bridging the gap in this digital divide with content mothers are seeking.

So what if you do not have wifi at home. What if you do not have a tablet? What if you do not have a smart phone with a good data plan to read these blogs. What if you cannot afford the large yearly fee of a concierge doctor? What if you are one of these 250k in South Carolina who could benefit from coverage afforded by the Medicaid Expansion. Overwhelming…imagine not having access to the resources necessary to receive quality health care.

Many people just do not even understand the idea behind the Medicaid Expansion, one of the many parts of Affordable Care Act. Let’s look at it from a 30k foot perspective in South Carolina. First of all, when the ACA passed the Federal Supreme Court, the justices ruled that states could decide whether they wanted to accept or not accept this part of the law. This gave each state the authority to decide whether this makes sense for their residents.

If SC would have passed Medicaid Expansion into the 2013 budget, it is estimated that close $11 billion dollars would have been awarded; dollars South Carolinians are already paying into this federal tax base each year. Essentially, SC would have been able to reclaim our investment to use those dollars right here inside our states’s borders. Instead, when SC legislators did not include the Medicaid Expansion in the 2013 budget…we as a state decided to allow the federal government to use our investment in other states that chose to expand Medicaid.

The University of South Carolina Darla Moore School of Business found that *if* SC would have accepted the Medicaid expansion in the 2013 legislative budget cycle, close to 44k jobs would have been created.

So let’s move past the economic development part of the legislation. Let’s talk about the people who need care would be impacted. There are close to 800k uninsured people in SC. These individuals are accessing care via emergency rooms, free medical clinics, community care organizations, or just not accessing care at all. Close to 250k of these individuals could have access to insurance if the Medicaid expansion was passed in the SC budget.

These 250k fall below 138% of poverty. For a family of three, that is roughly below $34k per year in gross income. Now if you fall below 100% of poverty, or about $24k per year for a family of three, you can receive care at most free medical clinics. But anyone above 100% wouldn’t to qualify for the services at many of thee clinics.

So this gap between 138% and 100% (between $34k/year and $24k/year) are struggling to afford insurance. With the opening of the new Health Insurance Exchanges, people at or below 138% receive a subsidy (tax credit) to purchase insurance on the insurance market place. But, we know that they will not be able to afford the coverage even with the tax break.

This is why the Medicaid Expansion was a vital part of the ACA legislation. Why? Because it knew these individuals needed care, yet could not afford it; and hospitals were over burdened already eating the costs for treating these patients. I’ve seen it first hand with my community hospital. It has been in red for years because most of the population it serves can barely pay for those services. Many of the paying customers in Anderson County are going to other regional hospitals for services like having a child, cancer treatment, orthopedics, or other large dollar services.

The Medicaid expansion would help offset these hospitals, like Anmed, financial burden given the income brackets of the community it ultimately serves. When AnMed released information regarding their charge master, many of the costs of services were much high than the regional hospitals in the surrounding area. I would imagine they are having to offset the costs of services they are providing for indigent care with the paying customers and the insurance policies that serve their needs.

So ultimately my insurance policy is more expensive because money I am paying into the system to create a healthy premium is offsetting the costs of uncompensated care hospitals are having to bear. So the longer we do not pass the Medicaid Expansion the longer the following will continue to happen:

1) Insurance Premiums for paying customers will continue to rise
2) Small community hospitals will continue to struggle financially
3) Emergency rooms will continue to provide primary care to uninsured patients
4) Businesses will continue to raise costs of services and goods
5) More physician practices will continue to struggle to do business
6) States that expand Medicaid will benefit from other state’s investments
7) Free medical clinics will become more and more overcrowded

As I sit here at my desk, I am thinking. Why is it so hard to help those in need. I see the people in this gap as the working poor. The individuals between 138% and 100% of poverty are getting up everyday trying to find a way to make money. They are working hard to provide for their families and find medical care.

So let’s move away from looking at the Medicaid Expansion as just a budget line item. Let’s look at it this issue through the same lens when we ask for federal dollars to attract large businesses to expand to SC. Let’s even remove the name ACA and Medicaid Expansion from the legislation menu. What if we gave it another name or even added investment to the title.


I know first hand one of the reason’s why SC is not expanding Medicaid. A few years ago, I visited the state house in Columbia, I watched a private citizen talk to a legislator about her community and the need for the expansion. The legislator responded, “anything related to Obama will not get a vote in SC!”

We know it will bring thousands of jobs to SC. We know it will provide coverage for close to 250k citizens in SC. It will not cost the state any money until 2017. Here is the kicker…it will provide access to care to those in critical need…who in turn will have a medical home, increase insurance transactions, and be able to be a part of a healthier workforce.

To created a skilled workforce…you need a healthy workforce…right? If you are living paycheck to paycheck…no insurance…no access to continuous care with a consistent provider…your stress level is higher, less education about healthy choices, and less willing to be a part of the productive society. This community is more prone to high blood pressure, heart attacks, strokes, and the list goes on.

So can access to insurance solve all these problems. Well…I have no clue. Are we creating another safety net entitlement program…many would say yes. Is the current Medicaid system being abused…yes.

So let’s ask these questions. Is there a need? Yes! I have met thousands of individuals in North and South Carolina who look just like me…hard working people in search of quality health care. They end up at these once a year free clinics.

Would health insurance increase access to quality care? Yes! Could a healthier population create a larger economic impact? Yes! Have we invested millions and millions in companies, roads, education with a less than desirable outcome? Yes and No! BMW, Boeing, Charleston Port, CUICAR, Amazon, USC School of Medicine at Greenville, and the list goes on…and were these great investments? Yes! So how about investment in population health to create a skilled, healthy workforce so we can continue to attract more companies to SC?

At some point we are going to have to get to the root of the issue…investment in the common people of SC.

So here is my final question, is it possible to create a plan like Medicaid Expansion here in South Carolina that is not called Medicaid Expansion? Is it possible to create a similar plan like Arkansas where we use the federal government dollars to do exactly what it was meant to do and not associate with the Affordable Care Act?

It is good for business to have a healthier, skilled workforce! We know it is costing companies lots of money and time when their employees are sick, out-of-work, yet no access to affordable care. Would they Republicans in South Carolina agree to a similar plan as long it is not called Medicaid Expansion and can create the perception they are creating something that is different than the President’s plan? Can the Democrats in South Carolina tuck their tales as well and not get upset when an alternative is offered that is not part of the Affordable Care Act?

I know this much…this will not happen in 2016. South Carolina is completely focused on the impacts of the floods which includes our bad roads and bridges. Plus it is a Presidential election year where the rhetoric nationally will be against the Affordable Care Act and anything President Obama put into place. Can South Carolina wait another year until 2017?