QCCT Fund for Indigent Care Takes a Further Beating in Kentucky Senate.

As reported in these pages earlier, the Governor’s budget (and that of the House) decreased QCCT funding for indigent care at University Hospital by 70% percent over the next two years. The justification for this decrease was that the new healthcare reforms being put into place would result in fewer patients showing up for care at Louisville’s designated poor-people’s hospital. Perhaps there were other reasons too.

QCCT gets zeroed out.
The Senate’s Budget Committee upped the ante by immediately eliminating this subsidy altogether! Senate Republicans justify this further decrease with an amazingly cynical bit of political sophistry. Senate Republicans argue that because every person in Kentucky is now eligible for some form of health insurance, that no patient will be eligible for QCCT funding in any case. Some folks may actually believe this. Of course not even the most ardent defenders of the Accountable Care Act (ACA) claim that everyone will be covered by the complicated system of programs and options that could be cobbled together against intense partisan opposition. Among other reasons, out-of-pocket costs to patients will still present a prohibitive barrier for many. Failure to fund the full “traditional” $21 Million program releases University Hospital from its obligation to provide care to all comers. There will still be plenty of work to go around for all Jefferson County providers to take their share.

It’s all about jobs. but whose jobs?
Frankfurt Republicans seem more intent on increasing their control in Frankfurt then they are in providing affordable access to health care for their constituents. Make no mistake, any shortcomings in the ACA, real or exaggerated, will be put up front-and-center in this Fall’s elections. The duplicity, both here and in the nation, is that those who did everything that could be done to cause the ACA to fail in any way, will now use any failure, real or imagined, as a justification to vilify the bill’s proponents. As always in our current political stalemate, it seems like winning is more important than serving. Both parties are equal-opportunity players in a system where making the other guy look bad is just as valuable as making yourself appear good.

Why make yourself look bad?
Also deleted by the senate was a House requirement for “the Cabinet for Health and Family Services and the University of Louisville to conduct an annual study of the effect of the reduction in contributions to the Quality and Charity Care Trust on the delivery of indigent care in Jefferson County,” or otherwise “direct a study on the delivery of indigent care in Jefferson County.” It seems to me that such a study (combined with greater transparency of how the money is actually distributed) is needed now more than ever! Of course such a study might also reveal any disaster that occurred as a result of the sudden-death nature of these interventions in this 30-year-old program. Individuals and institutions are both at risk.

Are sick people merely (legalized) gaming chips?
Of course whatever appropriations bill the Senate as a whole passes will be subject to negotiation with the House. Perhaps this can be done without a special session, but that has not always been the case. It has been reasonably suggested that the withholding of all indigent care funding for University Hospital is just a ploy to give the Senate budget negotiators a chip to play with. (All of the dozens of earmarks funded by coal severance money were similarly deleted by the Senate.) The plan is: take away something you were planning to fund anyway and then give it back in a magnanimous gesture of compromise. Others might characterize such a strategy as kidnapping for ransom, or perhaps just politics as usual.

Changes in QCCT not all bad.
I have been among the first to argue that the current structure of the QCCT fund has outlived its purpose and needs to be substantially revised if not replaced. I will not reiterate all the arguments here. I ask for greater transparency, equity, efficiency and justice in the use of these public funds. If we as a community expect our hospitals and providers to take care of everyone who walks thorough their doors, we have a responsibility to provide public funds to do so. Perhaps the Senate feels that only from a total meltdown can something better arise from the ashes. Their actions to date include no public discussion of those better ideas and little apparent sensitivity to what will happen to sick people or the institutions that take care of them. Shock therapy is not medically indicated here.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of of Medicine, UofL
March 26, 2014