Arizona Entitlements...To Expand or Not to Expand?

I had the wonderful pleasure of visiting the Arizona State Capital yesterday and meeting with a number of our state senators and representatives.  The big "hula-ballou" was that Governor Jan Brewer was also holding a press conference about her proposal for Medicaid, Arizona Health Care Cost Containment System (AHCCCS), expansion for our state. This has had a significant amount of media coverage, as Gov. Brewer a fiscal conservative, has decided to expand Arizona's entitlements by leveraging federal funds. Her press conference was held on the same morning the Arizona Osteopathic Medical Association (AOMA) was meeting with our state legislative representatives.  I was interviewed by News Channel 3's Dennis Welch, but only three seconds of my three minute interview was aired and it was taken completely out of context.
Here is what I tried to explain and my position on the issue. At first appearance, it seems that Gov. Brewer sprouted "progressive" tendencies and has given in to the Affordable Care Act ("ObamaCare") to which she has been historically and strongly opposed.  However, this is a very sticky problem, and it is important to understand the back ground on this issue to understand why this proposal has arisen.
It started in1982 when Arizona voted to enter the Medicaid program.  Arizona was the last state in the union to enter into Medicaid.  This brought on a number of budgetary challenges, and to solve this problem, the state "privatized" Medicaid, allowing a number of insurance companies to compete for and oversee the distribution of the care and funding in 1987 called the Arizona Health Care Cost Containment System (AHCCCS) and lovingly termed "access."  This allowed for tighter control and efficient use of the Medicaid funds.

Bigger challenges arose with the voter passage of Proposition 204 in 1995 and then re-voted upon in 2000, amending the Arizona constitution to mandate state health coverage of those residents up to 100% of the federal poverty level.  This means that no matter what, Arizona is constitutionally required to pay for and participate in Medicaid.  Part of the health care dollars have been paid for by an Arizona Sales Tax which was set to expire on December 31, 2013.  The renew of the sales tax was voted down at the end of 2012 and these funds will no longer be available.
Currently, the federal government matches Arizona's contribution to Medicaid at a 2:1 ratio. Because of budgetary AHCCCS enrollment freezes, childless adults that will not be covered, mandated changes to the plan required by the ACA, and the loss of revenue from the sales tax, AHCCCS will cost Arizona an additional $450 million dollars per year that will be required to come from the State's general fund.  This makes it impossible to balance the state's budget in 2014.
Because Medicaid coverage at a minimum of 100% of the federal poverty level is required by the state constitution, Governor Brewer is stuck with a difficult problem.  Services have already been notably reduced and reimbursement to providers has already been cut by 10% over the last few years.  Further cuts would cause providers and hospitals to drop the program like a rock.
The proposal, therefore, is to accept the Federal 9:1 match of funds by expanding Medicaid to 133% of the federal poverty level. This would actually allow coverage of an additional 60,000 Arizonians and would save the state $325 million dollars per year.
From the perspective of Health Care Policy, it is important to look at any policy in regards to cost, quality and access.  Governor Brewers proposal will allow her to balance the budget much easier, however, this proposal will not improved quality and only partially improves access.  The liberal side of the community is excited about the expansion of entitlements; however, the strong conservative side of the community is concerned that we are adding to the federal debt to balance the state's budget and strapping our children with today's burdens.  Because of increased access to services (modest as they may be), most physician and health care organizations have thrown their support behind Governor Brewer.
Will federal income tax increase in the future because of this?  Will the federal government actually have the funds to move the ACA forward? If the federal government fails with it's commitment, will that leave Arizona in a financial bind?  Does this affect our states sovereignty? These are questions that have not been answered.
I agree that something must be done, but is there another way to balance Arizona's budget without increasing  our state's dependence upon federal funds?

Legend Has It . . . How Diabetes Was Discovered and How That Makes Me Fat

The German physiologist Oskar Minkowki was the first person to identify the role of the pancreas in diabetes.  Legend has it that on a momentous day in 1889 Oscar  noticed that urine collected from his pancreatectomized dogs (dogs that had surgical removal of their pancreas) attracted a very large number of flies.  He is said to have "tasted" the urine and to have been struck by its sweetness.  (Only in 1889 could you get away with tasting dog urine.)  He then made a very astute observation and realized that the pancreas controlled blood sugar concentration and was a key factor in diabetes mellitus.
Thirty years later, Fredrick Banting and Charles Best identified insulin as the key hormone produced by the pancreas controlling the level of blood sugar.  However, what Oscare Minkowski couldn't taste was the very high level of acetone in the urine which is produced by the liver in the conversion of fat to ketone bodies.  Had Oscar lost his sense of taste, instead of noting the sweetness to the urine he might have noted the pungent smell of acetone.  He would have then concluded that the removal of the pancreas causes fatty acid metabolism to go awry.  He then would could have extended his hypothesis and concluded that the preeminent role of insulin was not in the control of blood sugar alone, but in the control of fat metabolism.
We have become fixated upon the function of insulin and its effect upon diabetes, and in doing so, we have neglected the fact that insulin has even greater effect upon the storage and use of fat and protein in the body.
A series of discoveries from the 1920s-1960s let to a revolution in the understanding of the role of insulin in fat metabolism.  At that time, fat was assumed to be relatively inert and carbohydrates were seen at the primary fuel for muscular activity (which is still commonly believed today).  The belief was that fat is used for fuel only after being converted in the liver to suspiciously toxic ketone bodies.  Forty years of research overturned this assumption, however, it had no influence upon mainstream thinking about fat gain and obesity.  In 1973 when all the details of fat metabolism had been worked out, Hilde Bruch, the foremost authority on childhood obesity, stated "it is amazing how little of this increased awareness . . . is reflected in the clinical literature on obesity."
JAMA just released it's compendium on obesity research and the simple science of insulin's effect on fatty acid metabolism is STILL being ignored. Instead, main stream medicine is starting to push patients toward a very expensive and risky gastric bypass surgery. This scares me.
Hippocrates said, "Let food be your medicine and let medicine be your food."  The body responds with hormonal effect to what we feed it and the science explaining this has been ignored. We have been brainwashed with the dogma that the "calorie is king."

Mayor Bloomburg eating donuts
two days after trans fat ban

Based on this we are now legislating food behavior.  New York has now banned trans fats by the New York City Board of Health and has legislated all soda sizes to no larger than 12 oz. We are creating health policy on bad science.  Let's go back and look at the science before we let our legislators start cooking for us, or soon our grocery stores will look like our government run school cafeterias offering school lunches.