The Taproot Podcast - Alabama Medicaid Expansion with Dr. Madeline Eckenrode

Episode Date: April 14, 2025

Alabama physician Dr. Madeline Eckenrode gives an insider's view of the suffering caused by the state's failure to expand Medicaid. Hear harrowing stories of patients with diabetes, substance use disorders and other chronic conditions who can't afford care. Learn how Medicaid expansion would lower costs and save lives. Most importantly, get inspired to join the fight for healthcare justice in your community! Resources and Organizations Mentioned in Interview Advocacy Organizations Alabama Arise Organization that does advocacy around issues affecting Alabamians, including Medicaid expansion Encourages Dr. Eckenrode to write her article about young adults losing Medicaid coverage Provides information about legislation and opportunities for civic engagement Helps people know when to lobby, who to contact, and when to show up at the state house Alabama Appleseed Advocacy organization that works on criminal justice reform and other issues in Alabama Successfully advocated to end the practice of jail managers pocketing leftover food budget money Works on issues with broad, cross-partisan appeal Media and Publications AL.com Website where Dr. Eckenrode published her article about Medicaid expansion Main news source for Alabama ProPublica Published an article about United Healthcare using algorithms to determine if people were using "too much" mental health care and denying claims Healthcare Organizations & Programs UAB (University of Alabama at Birmingham) UAB Medicine Where Dr. Eckenrode practices and did her residency Home of the STEP Clinic for young adults with complex medical conditions The STEP Clinic at UAB Specializes in treating young adults with complex medical conditions from childhood Treats conditions like cerebral palsy, spina bifida, organ transplants, lupus, etc. Equal Access Birmingham Student-run free health clinic affiliated with UAB Provides care for uninsured patients with conditions like high blood pressure and diabetes Cannot provide cancer screening or comprehensive services PATH Clinic UAB clinic for uninsured patients with poorly controlled diabetes Provides free medications REACT (Resource for Addiction and Community Treatment) UAB assertive community treatment team Works with severe cases of psychotic mental illness Cooper Green Healthcare facility funded by Jefferson County taxpayers Provides services to uninsured individuals in Jefferson County   Insurance Programs Medicaid Government insurance for low-income and disabled people In Alabama, primarily serves disabled adults and children Pediatric Medicaid coverage ends at age 19 in Alabama Alabama has not expanded Medicaid unlike many other states Has "pretty good prescription drug coverage" according to Dr. Eckenrode Medicare Government insurance primarily for people over 65 Some people who are disabled can qualify before age 65 People on dialysis automatically qualify for Medicare Blue Cross Blue Shield Private insurance company mentioned throughout the interview Various plans (state employee, federal, employer-specific) United Healthcare Private insurance company mentioned as "the enemy" by Dr. Eckenrode Largest employer of doctors in the country Uses algorithms to identify and deny claims for "excessive" mental health care usage in some states Recent Policy Developments Medicaid Postpartum Expansion Extended postpartum care through Medicaid from 6 weeks to 12 months New Medicaid Enrollment for Pregnant Women Legislation to make it easier for pregnant women to enroll in Medicaid in first 60 days Physical Therapy Direct Access Law Recent Alabama law allowing patients to see physical therapists without a doctor's referral Some insurers still requiring referrals despite the law States Mentioned as Medicaid Expansion Success Stories North Carolina Arkansas Pennsylvania (mentioned as having no tax on groceries or essential items) Disclaimer: The views expressed in this episode are not neccesarily the views held by taproot therapy collective. #MedicaidExpansion #AlabamaHealthcare #UninsuredPatients #ChronicIllness #MentalHealthAccess #SubstanceAbuseTreatment #PatientAdvocacy #HealthcareActivism #HealthcareCosts #HealthEquity #TaprootTherapyCollective #DrMadelineEckenrode

listening to your heartbeat realizing it's my heartbeat too cause if something were to happen to you listening to your breathing realizing it's my breathing too because if something were to happen to you Hi, welcome to the Taproot Therapy Collective podcast. I'm here with Dr. Haley Beach and Dr. Madeleine Eckenrode. Haley is a doctor of philosophy and social work. Dr. Eckenrode is a medical doctor who just wrote an article that we saw on ale.com about Medicaid expansion and some of the

effects of not having access to health care on women and young adults. I will let you lead us in because we want to kind of look at the way that some of these things affect Alabamians and probably people in other states too, with similar realities and hear from the people who provide care about that. Dr. Mr. James Waits at our practice sees his specialty as physician burnout and nurses and executives and doctors. And so he may pop in if he's able to. And you know, Haley's specialty, well, Haley,

can you talk about your work just so we know where everyone's coming from before we start the discussion? Yeah. Yeah. So my work really focuses on looking at birthing, birthing individuals, women who experience violence and women who experience trauma through their birthing experience prior and after. And so my work is really focused on that academically and professionally as a therapist wanting to work with that population, those women, but also interested in young adults and how they receive care and how they, they are able to navigate mental health in a time of life

that can be very complex. Yeah, and so, and then I do, you know, trauma therapy and so we're all kind of looking at similar, similar population from different angles, similar issue from different angles. So just to make sure everyone knows where we're coming from. So Dr. Ekenharn, could you tell us a little bit about your article and some of your perspective working at UAB and what you see there and

the effect that it has on just real people's lives? Sure. Yeah. So I am a med-peds physician. So I did a dual residency in internal medicine, so kind of adult medicine and pediatrics. And so graduated in 2015 or in 2019 from residency at UAB, did my training there. And then I now do mostly adult primary care. And so but I also specialize in young adults with complex medical conditions. So I have a clinic at UAB called the Step Clinic, where we see young adults who have very complex medical conditions from childhood, things like cerebral palsy, spina bifida,

but also kids who have had organ transplants, kids who have had, who have complicated immunologic things like lupus, things like that. So I see a lot of those young adults in my practice at UAB as well. And so, yeah, I really see the impact of underinsurance or lack of insurance every day in my life, in my practice. So I guess I wrote the article, I think, after years of kind of being like, why hasn't this

happened? Why haven't we expanded Medicaid? Because I just see how it impacts my patients every day. And I think I think I was talking to an organization called Alabama Arise that does advocacy around lots of issues that affect Alabamans, including the lack of Medicaid expansion here, and was talking to them about this patient population of young adults. And they were like, oh wow, this is something we haven't thought about. So young adults who have chronic conditions of childhood, things like Crohn's disease,

or they've had an organ transplant or type one diabetes, and then they lose pediatric Medicaid at age 19 unless they have parents who have health insurance that they're able to be covered under. And so they were like, this is an interesting population to write about. You should consider doing an op-ed. And so I did.

And it was published and had a really, I think, good response from people who I think a lot of, I got a lot of emails and pages and messages from colleagues who were like, I'm so glad you talked about this because it's something that is very real. We see it every day. And so I've been really gratified to hear that response from people who are like, this is an issue that is under discussed.

Well, and I'm glad to see more medical professionals, especially doctors who are kind of the top of the food chain for the medical establishment talking about that because I think not talking about it leads to these kind of confusions about like, I mean, a lot of people that I encounter, we've all as Americans probably had pain points with the medical system. I don't know that anyone is loving it. Or like any kind of political advertisement that pretends that like people love the healthcare

system. It doesn't make sense to me. Like I remember when Obamacare was first being discussed and people were like, your precious insurance plan, you might lose it. Don't we all curl up by the fire with our insurance plan every night and hug it and kiss it on the forehead. And it was like, cable companies, airlines, insurance. These are things that I don't know

that anyone's having a great experience with. But I think a lot of that anger gets directed at doctors in ways that aren't fair by people who don't really understand how that system works. And it makes sense because the doctor is the one telling you, I don't have time to see you, or the, you know, scheduling for UAB is the one telling you, Oh, yeah, there's something seven months from now if you want to get a referral for therapy, but you have to have primary care first, which is Blue Car's Blue Shield's decision, but it feels like the white coat is out to get me. And a lot of that, I mean, I understand the reason you wouldn't wanna talk about some of these things, but it seems like the response to your article has been good.

I wonder if you could say anything about that engagement, good and bad, and the conversations that maybe you see. Yeah, yeah, I think that's right. I think there's been a loss of trust towards doctors and that's very complicated and we don't, that's not kind of the topic of this conversation, but yeah, I think that being transparent about some of the struggles

that we have to care for our patients effectively is good. So patients know that. And I always try to be honest with patients. And I think that a lot of times patients think that anything we say can overcome insurance company barriers. And that's not always the case. And so it's often not the case.

And I've literally cried on the phone with insurance companies during prior authorizations because I'm like like if you deny this like this patient might die and like and then usually it does get approved but like then I have to like cry like that's crazy like um but anyway yeah so um well and why are you the one telling them you know what I mean one why are they why are they the one telling you that you need to change your medical care as the one who's licensed to provide it and has the encounter with the patient and the access to the test

results and you know, like all the healthcare data? And then why are you the one begging them to explaining to them that the patient might die? I mean, what is that system? I don't know. And like prior authorizations required for like generic medicines like albuterol, you know, it's like albuterol is a life-saving medicine. It's a generic medicine. It's been around for 50 years. Like, why do I have to like-

It's not even expensive. Why are you gouging that? I don't know. Yeah, so it's really crazy. And I probably do like four hours of paperwork every week related to medication, kind of prior authorization and stuff like that. And so I and that just stinks. But yeah, so insurance, yeah, insurance kind of is the enemy as far as I'm concerned. In terms of preventing good care

for patients and, you know, huge money making corporations that don't care about patients at all. You know, I think a lot of stuff about United Health Care that has come out is is is true and is bad. Like there was just a ProPublica article about how they in certain states use algorithms to see how if people are using too much mental health care. And then they start to use the United United Health healthcare in certain states. It's been outlawed in a handful of states But in certain states they they look at at yeah Healthcare claims by individual and if they're using too much healthcare and mental health care so getting too much therapy You know is there too much?

It's such a thing but they think there is and then they start denying their claims Which as you know for people was like serious psychiatric illness like schizophrenia, they need a lot of care. It's bipolar, where you're clinging to your ability to make good decisions before you go into mania and they can feel it and they're begging for help. I mean, those are the cruelest phone calls we get because I can't prescribe medication. I can tell you how long the wait is and that is dour answer. Exactly. So that was just revealed

that they're doing this in certain states and have algorithms to look at these claims. So anyway, they're the enemy as far as I'm concerned. However, people do need insurance to get care and out of the Medicaid is actually fairly decent in terms of at least prescription drug coverage. So I see this happen a lot where people, they like fall off and on Medicaid, especially young women. in terms of at least prescription drug coverage. So I see this happen a lot where people,

they like fall off and on Medicaid, especially young women. You've probably seen this, Hailey, who have babies and then they're on Medicaid for that time and they get a little bit of access to care. And then that Medicaid goes away. And so then their health suffers. And so people, I see that in my practice a lot. I'll see people for a couple of years,

and then I won't see them for a year or two because they've lost insurance. And then their diabetes becomes really poorly controlled. And it's like, why do we have that? Why can't we have a system where people can get care when they have job loss or when they're having to care for a relative or when they have a serious illness themselves

that sidelines them. And this is a very personal thing for me. So I have a brother who struggled with addiction and he's in Pennsylvania and he was able to have Medicaid, which actually paid for his recovery. So at a recovery center, and then also paid for mental health care and paid for therapy and paid for him to see a psychiatrist and

and now he's been in recovery for about six years and he's had a full-time job that whole time. He has a wonderful girlfriend. He's a taxpaying citizen. But if he hadn't had that Medicaid when he was in his 20s when he was struggling with addiction, he would be dead. And so it's like, but now he's living a really wonderful, full life. And it's like, why don't we want everyone to have that safety net of insurance coverage when they need it to help them like stay healthy, get healthy,

and then hopefully one day, you know, get jobs that have employer-sponsored healthcare. But not everyone can do that, but a lot of people can, as long as they have a little bit of help through vulnerable times. Haley, you do some work with people that have caregivers with kids with chronic issues and different things. I wonder from your background and research, if you could tell us some of the statistics about Alabama and anything you want to respond to there?

Yeah, yeah. I mean, kind of to bounce off what you were all saying, I mean, our healthcare system is so reactionary versus being proactive and trying to keep people healthy and preventative care is so critical. But often that is not the focus of healthcare. It's, it's when we get to crisis, chronic conditions that are so difficult at some point to be able to manage. And we're having to make tough decisions as providers and support our clients and patients in those decisions when there really are few options.

I know for populations, the populations I work with, the birthing community, Medicaid is huge. The majority of women, a lot of women use and rely on Medicaid. And the Medicaid expansion that took place post-COVID, where they expanded postpartum care for 12 months was really critical. And I think one of the most important things

that they could have done, because statistically we know that women, while they do experience postpartum and can have a lot of physical and mental manifestations, postpartum within six weeks, really we're seeing that women are experiencing the highest rates of postpartum depression and postpartum psychosis and these conditions up to 12 months. So really when you have one six week postpartum visit, you're barely into being a parent coming out of birth and then you're just dropped.

You don't have care. And so that expansion was really critical to allow women to continue to receive care where we see the majority of postpartum mortality is after maternal mortality is postpartum primarily. And so that was really critical. I wanted to ask about the new Medicaid expansion? Are you familiar with how they're expanding the first 60 days while getting on Medicaid for pregnant women? I was reading about it and that's, I think KIV is about to sign that into law.

And so I think that's for, that is for, oh, okay, yeah. So basically kind of making it a lot easier for people to get on Medicaid when they're pregnant and like removing some of those barriers. That's what I understood. I don't take care of pregnant women. So I was like, that sounds good,

of removing those barriers. But I mean, I have some young patients who do get pregnant, but I'm not an OB-GYN, but it seemed like there were some barriers to signing up for Medicaid when you are pregnant and that Medicaid law was removing those barriers. That was what I understood. Yeah, okay.

I mean, I think that's how I understand it too. I think, you know, in theory and practice look very different. So I think it sounds, it seems like a good thing and I think that it's gonna be a positive move but it'll be interesting to see how it actually plays out for women because I think that's where it really, we see the impact of these policy decisions trickling down

directly affecting individuals in the community. I did have a question for you around the Medicaid gap and particularly with your population as far as those individuals as young adults who don't qualify, they they don't make too little to qualify for Medicaid but they make too much, sorry opposite way, they make too much to qualify for Medicaid but they don't make enough to really have like Blue Cross or private plan. What do those individuals do?

How do they cover their care? Yeah, I mean, sort of a hodgepodge. So essentially if you are a non-disabled adult in Alabama that doesn't have children, you cannot qualify for Medicaid no matter how low your income is. And so, and yeah, so, yeah, I mean, so some of them buy really bad marketplace plans, so which should be outlawed, like one of the big benefits when people said that you lost insurance under Obamacare. It was like, no, it's just not legal to print insurance on a piece of paper and then sell it to people anymore. But there's never really plans that you could eke any care.

You could never really milk any blood from that turnip. But those are the plans that got criticized as going away under Obamacare, which a lot of that's been rolled back, unfortunately. Yes, exactly. So actually actually UAB stopped accepting one of those United Health Care junk plans because it was so bad and so if you have that plan all of your appointments at UAB have been cancelled and so they will not like let you step foot in the door. So I have a couple of patients who signed up for that plan unfortunately

and so I won't be able to see them at UAB. And so, you know, so yeah, signing up for bad plans. That's one thing people do just being uninsured. You know, that's another thing. So sometimes if you're within Jefferson County, you may be able to access Cooper Green services. If you're outside of Jefferson County at UAB, you can apply for charity care at UAB, which is somewhat onerous and doesn't really cover everything, but at least it's some sort of stopgap. But I would say, you know, a lot of those people are just

uninsured. And so those are the people I see at Equal Access Birmingham, which is like our student run free health clinic. And, you know, and it's good. There we can see a lot of patients who have, you know, high blood pressure, diabetes, and generally can manage it fairly well. UAB has another clinic called the Path Clinic for patients with diabetes, where they can get free medications if they're uninsured and they have poorly controlled diabetes. So there's some of these options, but for instance, at the free health clinic, we can't do any cancer screening. So it's like talking about preventive healthcare, none of those are covered.

We can see you, check your blood pressure, check your blood sugar, give you some medications for free and not, we don't have like a comprehensive formulary, but yeah, so it's like, no, it's not a good situation. So you can maybe cobble together some sort of plan, but it's not optimal and that's what happened. So, and I have appreciated getting to see these patients who are uninsured or underinsured at the free clinic

because I really then see a lot of the barriers. And a lot, almost all the patients I see at the free health clinic work. There are so few who don't work, but a lot of them are doing things that are landscaping or working in service industries like restaurants or just working part-time because they're caring for an aging parent or something like that. So I would say it would be interesting to know the statistics.

I don't know them, but I would say just anecdotally, most of these people are working that I see at the free clinic and yet they still don't have access to insurance. Well, and a lot of, you know, I can hear like, the comments on this already about, you know, well, who's going to pay for it or whatever. And the thing is, you know, there is in medicine, hard decisions, you know, that I don't know that I'm equipped to solve, you know If somebody's getting close to the end of life and they're already, you know 85 and they need a million dollars of care or something You know what? Those are hard questions. A lot of these questions aren't hard. I mean you mentioned I've been all in the beginning It's not like it helps anybody It's not like it even saves that money that much money

Like there's not a reason to do any of this stuff. And in most cases, it's more expensive for the state. So the people saying like, well, who's gonna pay for it? You will put you will you will pay less, we will give you money. Just listen, you know, get a QT. The like a buterol is, you know, an asthma man. It's an animal axis man. No one is is like, well, yeah, a lot of free healthcare. Let me go to the buffet and it's been a long weekend and let me, you know, like what is the reason

to withhold this thing that is old as dirt, generic, cheap to make, and a emergency life saving med that is not abusable, you know, like has a long expiration? Like what is the reason? Why do that other than just you have the power to do it and you want to see what we can get away with? And I mean, the who's paying for it question is really interesting. You're exactly right. You are. So I mean, the taxpayers of Jefferson County are funding Cooper Green. You know, UAB is passing costs along to you when it gives a lot of care away for free, charity care.

So, and that's very complicated because it's a tax, you know, it's a nonprofit and that's very complicated. The nonprofit of UHSF that is fully designed to help the for-profit of UAB make money. Right. Yeah, so it's not like- It's illegal, it's not, they're not doing anything wrong.

Yeah, I can't, you know, I don't know what to really say about that. But yeah, the answer like is more preventive care. And I just, you know, because it's like, if you don't care for that person's type one diabetes, they're gonna need a kidney transplant in 10 years. So what's gonna happen is they have kidney failure because of their type one diabetes, then they go on dialysis. And so then they go on dialysis. And so then they automatically qualify for Medicare. So then you as a taxpayer are paying for that. And then hopefully they can get off of their dialysis

and get a transplant, at which point then they stop qualifying for Medicare and Medicaid because they're no longer disabled by being on dialysis. And then hopefully they can keep their transplant through some means, but it is, it's, it's really messed up. And I'd like other states have seen so much benefit from Medicaid expansion. I was really excited last year when our state lawmakers heard from North Carolina and Arkansas

about the successes of expansion in those states. And like, they were like, yes, it's wonderful. It's saving rural hospitals. It's like saving lives. Like there was one congressman from North Carolina, a Republican congressman from a rural district who basically said, I was against this. But as soon as it passed, I had all my constituents coming up to me thanking me and saying, I had a relative.

I had a friend who benefited from this. And so his mind had been changed. And earlier this year before the presidential election, Blue Cross was coming in saying like, hey, we might be able to do a partnership with you, a public private partnership, like essentially what all kids says and do that for adults, which is what was done in Arkansas.

And so it was like, there was hope when there was still kind of thoughts that there would be federal dollars coming in if Medicaid expansion occurred. And now that that's in question because of federal funding cuts in the budget, I think that that's not gonna be politically tenable, but it was really exciting

that there was actually some hope because I think, you know, I just so many, like I, there's just too many stories to count of people who would be positively impacted by this that I see literally every day. Well, and so before I did private practice, I was with UAV React, which is an assertive community treatment team. And we take and talking to the viewer too, even if you guys know what these are, but they take some of the worst cases of psychotic mental illness that are very expensive. And one of the reasons why Medicaid pays more for that, a lot of those patients have been in Bryce multiple times.

You usually have a severe mental illness, but also comorbid with something else like an addiction or a personality disorder. And it really takes a lot to be on that team. They don't just take anybody. And a lot of the time patients that have schizophrenia or addiction or something, they're going to the ER a lot. And then that's really expensive.

So assertive community treatment teams with this model to bring down the cost, because if we can pay a little bit of a stipend for apartment and show somebody how to get on SSDI so that they can pay for the apartment and some of the, and then just have medication and become stable, they become cheaper because if they're homeless, there's court costs,

there's law enforcement costs, there's property values going down, there's panhandling, there's maybe crime, there's all of these things. Not accounting for any of that, the team had been around a while and a couple of years before I was on it there was a doctor who

was from New York and was doing some research paper and asked if they could got permission from UAB to go through the data and The you know a team like that has a couple social workers, which I mean, I know don't make much Because I was on it, you know nurses and Psychiatrists, so they're not terribly expensive. It's about, depending on how their staff, 12 to 15 people, they can see about 13 people per person on that team per year. And the doctor went and looked at all of it and was like, you guys are saving just in Medicaid,

because you could go through the data, like about a million dollars per person for the state. So for the $30,000 you pay me, you know, you get $34,000. You make, you're getting, and I could see five to seven people, you're essentially saving five to seven million dollars. I mean, that investment is unreal. I mean, to pay $34,000 and save five to seven million, and you've got two of these teams in the state and you're fighting to shut them down. And you're saying like, well, why are all these social workers, whatever? Why is it the basic economics people that pretend that this is about money? It clearly is not about

money. You know, 100% so I actually I have several react patients in my clinic, I just saw one on Friday. And she is so sweet, but has had a lot of abuse and abuse of head trauma and has mental illness and intellectual disability and you know prior to being on React was in the ED all the time just like with a little complaints but you know like when you don't have any education or you're worried about your body you go to the emergency room because you're scared and so and now she hasn't been to the emergency room

in like years and she like, she comes to see me often. She has some pain, but we got her set up with aquatic physical therapy and her workers make sure she gets to that and she's feeling so much better, doing a lot of healthy habits and like, she's just like thriving. And I see that in a lot of my React patients,

like they, the React program is wonderful. And you're exactly right. It's not about saving money because we know preventive care and things like that save money. It's about, I don't know what it's about. I think it's sometimes about racism, sometimes about who deserves things

in our state, in our society. Well, no one has enough. And as you cut these benefits and you create a crisis, I mean, people, I think, get angry enough that they're like, well, fine, I'm just gonna blow the whole thing up. And that's what you're doing when you can take more and more preventative gateways away and you force the whole system into crisis,

you put everything on emergency care. And emergency care is incredibly expensive and also not designed to treat things like dialysis and diabetes medication and just everything preventative cholesterol, you know. Yeah, it's so wild because it, you know, in so many social issues there isn't the infrastructure, there aren't, there isn't the evidence-based, you know, research that says these care teams are impactful, but in medicine, we know a lot of that works. We've seen it work. We've seen it work in other states.

We know that it can be beneficial, and yet we still cannot move the needle forward in trying to help individuals, politicians, look and understand that these measures, if we're treating them upfront, is going to reduce costs, going to reduce workload, going to reduce trauma. I mean, I think about the medical trauma that these patients experience, you know, just to stay with the example of the albuterol, If you have a client patient who uses albuterol and gets that treatment upfront and it gets that support,

they're not having to interface with the medical system as much versus what you were saying, they're not getting what they need. And so now they're having to have chronic conditions managed and going to the hospital and the ER and the medical trauma that those individuals experience, as well as your medical teams, your medical professionals, because they are put into Christ

like everything's on fire all the time. You know, it's hurry, hurry, hurry, fix this. But it's like, you know, you can't put a bandaid on a bullet wound. So I mean, I think those things are important to think about as well. Dr. Eganard, could you speak a little bit to, because you're talking, we're talking about some issues with private insurance and some issues with Medicaid, and they're both important, and people may not know how that works,

but there are, and there's some overlap in that. You know, like the Medicaid expansion you're talking about, it's kind of like saving for retirement. Like you pay money into it and your employer matches you. Alabama is leaving a lot of money on the table by not investing in these things because they get the money back. And then the relationship between, I think a lot of people think Medicaid just does its own thing and then private insurance is over here, which isn't really true. Medicaid is going to be kind of the gold standard of like how to chart and the way the system is thinking and then

Insurance is going to reflect that I mean our practice has to try and predict what's going to happen because it means that we need to change the way that we do things and You to do that you look at what did Medicaid do now? What is Blue Cross federal doing in DC and then you know that the plans that are the state Blue Cross plans are going to be a reflection of that eventually. And insurance just says all the time, we're going to do this, this is a new policy, everybody, you know, and things that are like really life-changing and then most of them don't happen. But one of the best ways to kind of predict what an insurance company will do is look where Medicaid's going. And could you talk a little bit about the economics of that for people that may not be familiar?

Yeah, and so I guess I think private insurance look at Medicaid but also Medicare. And so, you know, Medicaid is governmental insurance for low income and disabled people. And mostly in Alabama, it's for disabled adults adults and that is who qualifies for Medicaid and then Medicare obviously for people some people who have who are disabled can qualify for Medicare and so can get Medicare before the age of 65 that's a little complicated but but for most people it's people who get you know insurance after 65 and then for some qualifying conditions I mentioned, if you go on dialysis, you qualify for Medicare.

But yeah, so Medicare and Medicaid and the Centers for Medicaid Services and CMS, they do set a lot of policy precedents for what medications are going to be paid for. And yeah, private insurers definitely look to those. And so, you know, private insurers, I think sometimes people are like, I have Blue Cross. And it's like, oh, gosh, what does that mean? Like, you know, because the state employee Blue Cross is different from federal Blue

Cross is different from specific employer plans that are contracted with Blue Cross. And so I think patients don't understand that there's a lot of diversity within employer-sponsored plans and within private insurance plans. But yeah, they do look to Medicaid and Medicare to see sort of coverage. And like I said before, Medicaid actually has pretty good prescription drug coverage for a wide variety of conditions.

So I rarely have it be the case that I wanna prescribe something to a patient with Medicaid that they're not going to cover it. So prescription drug coverage is pretty good. There are some things that they don't pay for, like they don't pay for home health. So Medicaid doesn't pay for home health, which is really a challenge if you have a patient

who needs an in-home health service. And so there's definitely some limitations. There's also limitations for who accepts Medicaid. So a lot of, we have a lot of struggles getting patients in for physical therapy and occupational therapy because that only like hospital associated practices will see patients with Medicaid for those services. And so there's challenges with Medicaid,

but overall it's pretty good. I think private insurance actually tends to be more of the issue when we're thinking about drug coverage, which I think is the thing that impacts most patients is drug affordability and cost and things. And so those companies are trying to save money. And so they have a big incentive to deny a lot of medications. And so it was a private company who required a prior authorization for albuterol.

And so those companies are, yeah, very much trying to save money, trying to cut costs. They're also, I think, trying to make it difficult for patients and physicians so that they just give up. So like, you could maybe get this covered, but it's so onerous to get it covered that you're just gonna give up. So yeah, you could maybe get this covered, but it's so onerous to get it covered that you're just gonna give up. Oh yeah, so I don't really see that with Medicaid,

which is nice. It's pretty clear what's covered with Medicaid too. So there's a list called a formula that you can look at and see if it's gonna be covered, if it is, if it's gonna require prior authorization, where there's nothing like that for private insurers. So you kind of have to guess, you're like, I hope this is covered, it may be covered.

And then you prescribe it and then it's like, oh no, it's not covered. And then it's like, well, what is covered? And then like, well, you don't know, your patient's gonna have to call the insurance company and ask them what's covered for all this. And then it's, they still don't tell you. I mean, that's every time they put enough bureaucracy

in front of you and what you want, then there's less people that are gonna complete it and then there's more money that they get to keep. And so, in a lot of what you're talking about, I mean, I went through with my doctor, like you've got seven medications, you have no idea which one they cover, but it took you three weeks to figure out

after three referrals that they weren't gonna cover this one. So, three times seven, is that how many weeks you need of the doctor's time to try and, I mean, I luckily had a doctor that was willing to work with me and you know, wanted to fight with the insurance company. But, I mean, we see a lot of people at our practice saying they want to leave healthcare because of the amount of paperwork. And the amount of paperwork, I mean, I think over documentation and bureaucracies is a thing that medics and has always kind of leaned into. medicine has always kind of leaned into, but most of the growth in paperwork, just the explosion in documentation that is getting doctors burned out and leaving the profession comes from private insurance companies recently.

Yes, yeah, and 100% does. And it's just like, it's so frustrating for everyone. And it's just a really impedes care. And, and I mean, it's like, why aren't all generic medicines just covered? You know, they're cheap. Like, why should I ever have to do a prior authorization for a blood pressure medicine that was approved in like 1988? You know, it's like, this has been around. It's good. It's like, it's why?

Like, I don't know. It's, there's no rationale. And it has to do, I know with like the contracts that private insurers have with drug companies. And there's a lot of complexity there, too. But it's just there's no reason why health care companies should be billion-dollar businesses and be paying their executives tens of millions of dollars when they won't cover like a generic blood pressure

medicine or they will cover it but you have to do a lot of paperwork and have a phone call with you know with a peer-to-peer you know to talk about it it's it's it's really sad and and sometimes I just want like my patients to shadow me and like be like come and like see and like most of my patients are sweet and they're like understanding and I communicate with them, but I just want everyone to come in shadow and just be, this is what it's like. We're trying to do our best. I think most doctors are really trying to do their best to take care of patients and to fight for patients, but it is hard to have the energy to do it every day. Well, and if you're requiring prior authorizations or referrals for things that seem unrelated, you know, like if somebody has a sexual assault and

they want to go to therapy, why does the insurance company tell them that they have to go get their cholesterol checked first and wait six months when we know that the faster you get care for trauma, the cheaper it is for the insurance company to treat, you know, because the faster you get better. You make a trauma sip for seven months so that I can go see my primary care doctor to get a referral to go to therapy. That means that trauma has festered

and is statistically gonna do more damage to your life and neurobiology. Yeah, 100%. And there was just a law passed in Alabama that you can see a physical therapist without a referral, which is awesome. And but then like practically, some insurers are still saying no, you actually need a referral. And it's like, well, this is a law thing, you don't need a referral. And like, you know, if you like, tweak your knee while playing basketball, like, it's okay, just go see a physical therapist. And if they, you know, if they're like, Oh, this isn't getting better, like, go and see your doctor. And then like, maybe you need some imaging or whatever. But it's like, the same with it should be the same way for therapy as well. Like if you know, something bad happens to you, you know, a death or a job loss, like, you know, that you just want to maybe talk about it and seek therapy. And why can't you go and do that directly? It's crazy.

Like, you know, therapy is not a harmful intervention. It's not like we're saying like patients should be able to go and buy like fentanyl at the pharmacy. You know, like it's not a harmful intervention to like get therapy, you know, it's just crazy. Yeah, it's not an abusable addictive. Yeah. I mean, it's so clear, it's so evident

that it's such a predatory model, particularly for low-income individuals. Because you think about just all these phone calls and conversations and points of contact, that's if you have the time around your two or three jobs or four jobs that you're working and how much mental capacity do you have for that? Are you a parent?

Do you have other responsibilities? I mean, most people can't just sit on the phone all day and try to get this $4 prescription cover that would be life changing for them. I think it's just it's set up for people to fail and to give up, you know, and it's just, it doesn't need to be that way. No, it doesn't.

Yeah, it's, yeah, really at every turn, it feels very broken. I think like why I'm such an advocate for Medicaid expansion is that like, it makes things better for people. And I just see it so clearly when people are able to get on reliable insurance and get that primary care and get their chronic conditions treated. It's an intervention that is so impactful.

And it's not perfect. Like I said, Medicaid doesn't cover everything. But it's so much better than nothing, you know, where patients are using the ED or not or getting really sick. And so it's such, like, I don't know how to fix private insurers. Like, I think that needs to be, there needs to be massive reform there.

So, and I don't know how to do that, but I do know from my own personal experience and then also from all the data from other states with Medicaid expansion, it does good stuff. It saves rural hospitals, it saves lives, it saves money. It's all the good stuff. So from the economics people, we know it saves money. And then for the bleeding heart people,

we know it saves lives. So it should be something that we're all on the same page for. Well, and the people that moves the needle on so many secondary issues that the people who claim that it's about money claim to care about, like a highly qualified workforce, like encouraging people to work because they actually, if you can't afford a car, an apartment and insurance in because they actually, you know, if you can't, if you don't can't afford a car and apartment and insurance in America, why would you work, you know, you kind of need those things to function. And then property values. I mean, what, what do you want to look at what the differences and states

where, you know, Medicaid is there and the amount of people that move there and invest in those places? I mean, these things matter. And this is basic economics. So don't say that and then advocate with these things when you can't look at a pie chart. It's objective data. We have it. It's not an opinion. No, and it's hard because it's like, we want and need people to work low wage jobs. Like you want your people to work at McDonald's or work at a gas station or work at these places because as a consumer, you want to have those things. You want to be able to get gas and not wait in line. You don't want to wait in line at fast food, all that kind of those things. But most of those employees aren't given full-time schedules that would entitle them to health insurance. And so it's like, if you want society to function as it's functioning,

you should want those people to be able to work there and yet still stay healthy. It's a win-win. It just comes back to the fallacy that poor people don't work hard, so therefore don't deserve anything. I think that that's just a core misunderstanding that a lot of people have, or they think, I've worked really hard to get what I have, other people can do the same thing. And it's just that classic mentality that I think was ushered in the Reagan era and like really has been really sticky and hard to debunk. Well, I think that like there's this idea that... One second, sorry.

I'm losing my train of thought. I apologize. I need to cut you off. It'll come back to me. Hopefully I can cut this. I remember, yeah. So I remember like in the 90s all the way back then, like that people were talking about the cost of healthcare getting to this point where it would just not be sustainable and that it would be not be sustainable and that it would be the big corporations that would say, we want a public option or we want more regulation on insurance. It's something that kind of count because the pendulum couldn't swing so far the other way that there would have to be some way where the federal government was getting more involved

in the cost of insurance were more kind of spread out and shared from a public option or something. And that eventually this will have to happen was the conversation then because it's so unsustainable and it's becoming so cumbersome that it'll happen when the corporations want it to, because they're the ones with all the money in the lobbyists. It seems like now they're just being like, well, everyone's gonna be a good worker,

everyone's gonna be working for cash at a bar. Everyone's gonna be working food service. You're gonna be delivering Uber Eats till your 40s. You're gonna be delivering Amazon package, Prime, whatever, contractor. And insurance just isn't part of the American dream. I guess you just need to die. And they sort of bypass that thing. It's not the system is more sustainable. It's just that like we have less hope, which is terrifying.

I don't know. Yeah, yeah, no, it's so true. I think we, yeah, I think we have less hope. I think people can be working really hard and not have a good quality of life. And I think we've somehow decided that that's okay. Yeah, I think of, I have, what I've seen, I've mentioned that I have patients who like lose insurance and I don't see them for a while

and then they kind of come back. And sometimes when they come back, they are working at Amazon warehouses and they do have insurance because that job pays $15 an hour or more. But working there is so predatory. So I often see patients with repetitive use injuries. I had to write a letter for a pregnant woman

to say that she could use the bathroom more than like once every like three hours or something that she was allotted to. Cause like everything they do is timed. And so it's like, it's awful. Like I have seen the really bad impacts of Amazon, my patients in terms of their health, but they want it because it does have health insurance

and it's this carrot that they dangle. And it's just like, ah, it's such a catch-22 that if you're a poorly educated or a poor person, it is nearly impossible for you to find a good stable job that with health benefits that is that allows you to have a good quality of life like it's very very hard I just don't really see it like you know people are you know either working yeah I have this woman who works at a big national corporation and they can't keep employees because they don't

pay them well so she's working like 70 hours a week and filling in shifts and her employees are suffering and she's working really hard and she does have benefits But it's like, you know at a cost. So yeah, it's health care is embedded in a lot of larger other issues Well, I guess and it was kind of a final question for you guys because you you know, but both are in encountering policy I mean, I don't see like a great political path I mean, there's like, definitely parties that are like more, a party that is like more hostile to any kind of regulation. But it's not like I see the Democratic Party really running with any of this stuff, either. I mean,

sometimes they kind of give it lip service, but there's nothing that really happened that seems like it behooves everybody who has any kind of power to just sort of squat in front of the levers that control this stuff and pretend that they kind of want to press them. But when they have the ability to do it, just not. And so what do you think is effective? I mean, what is effective at getting things to be different? Is that more of a kind of community, you know, bottom up approach? Is it a different way to coerce power to do something that it should? I mean, what do you feel like is works? kind of pro people policies and Alabama is one of those states. I mean, and so I do think that that does have to do with

political party alignment. I mean, I just like that we as a state seem to be like pretty okay with a lot of like human rights abuses and things like that. And so like I think about our like state prison system and like and like exist. I talking about prison prison healthcare is a totally separate, terrifying thing anyways, that we could do another episode about. But anyway, yeah, so I think like, I do think that, yeah, what is the solution?

I mean, the solution to like under insurance is Medicaid expansion and it's worked in other states. And so it's like our state just has to listen to the testimony of other similar southern states, like North Carolina, but in Arkansas, and just has to decide this is what we want. This is good for people. But I think it's so hard because our state lawmakers don't

really seem to necessarily want to do what's good for people. They want to advance agendas that are, I think it's so hard because our state lawmakers don't really seem to necessarily want to do what's good for people. They want to advance agendas that are, I think, just meant to, I don't know, really want to pander to national politics. Where it's like this has nothing to do with what it was like to live in Birmingham or Mobile or Florence, Alabama. You know, why are you talking about this national stuff? Yes. You're talking about the Reagan era But I think I saw that happen too as a kid when when Clinton came in and Gingrich was basically like all politics are

National now, you know, these are the two football teams and before that it really was like, all right I want to vote for the comptroller. Here's the Democrat. Here's the Republican. I'm a Republican, but the Democrat has these ideas I like that, you know. It's a comptroller. Why would I care what he thinks about the president? And it sort of did become football around that Reagan, Thatcher, 80s, 90s realignment. Yeah, no, totally agree with you. I think the answer is keeping politics local

and getting involved in kind of local. And that's like what I decided to try to do like personally when I when I was just like, gosh, this feels really hopeless. Like, what are some things that I can do and like getting involved in organizations like Alabama Rise, Alabama Apple Seed that like are doing things that are clearly good. Like Alabama Apple Seed, you know, got rid of the idea that jail managers could basically pocket extra money that was left over in the food budget after feeding inmates. And so that led to-

That's articles. This year, I pocketed like $200,000 from potato flakes from the hands of the prisoners. And I think anyone across the political divide can be like, that's not good. Like, you know, like we can't start But also it's like comically funny, like I don't care what your politics are. Like some of this stuff is like so horrible. Like, can't we just laugh at it together? And so like, that is what I think the answer is. I think the answer is like, hey, let's try to like make things better in small ways or like reducing the grocery tax that we're slowly chipping.

He wants to pay grocery tax. I remember coming here and being like, what, there's grocery tax? Like Pennsylvania doesn't tax groceries. It doesn't tax clothes. Like, you know, it doesn't tax essential items. And like I was like, it was like, wow, living here is like a 10% increase in, in, in paying for groceries. And that's, that's a lot. So yeah, so I think like, the answer is coming together on small issues that everyone can agree on, because like, everyone can agree on stuff, you know, like you said,

it's sometimes it's funny, but sometimes it's just like grocery tax, like, no one wants to pay this, like, it doesn't make sense. Let's try to get rid of that. And so I think that's the answer right now. Maybe things will change and we'll have less political division and there will be better answers. But the answer right now, I think, is to work on these smaller things. Well, I think there I hear like a lot of opining about how they there's so much political dissension and hostility and we're more divided or something.

And it's just kind of like, I mean, maybe like we are, well, but the real political issues, I hear everybody saying the same thing about, like it's almost like we must have politics for something else. Like when I see people talking about manners, they're like, well, this guy's rude or this guy's whatever. And it's like materially, what did they do?

Like, I don't care if they talk like you and look like you and whatever, like, did they do? You know, like I don't care I'm like if they talk like you and look like you and whatever like did they do something that you like and There's this kind of need to make politicians I think like marble superheroes where they're like No, you elect people that go out and inspire and they represent and then the kids look at them and like No, like they're not supposed to be cool. They're supposed to make roads and food. And if they haven't done that, I don't care. You know, that's their job. And I don't know. So it's almost like it may not be that big of a realignment. It may just be a focusing on what everybody cares

about, you know, and instead of this kind of game. I totally agree. And that's kind of what I tried to do with this article was try to like, appeal to people to be like Look like they're all of you know someone who would benefit from Medicaid expansion Everyone who's reading this I think would think oh, there's someone I know who would have benefited from this And so like like if that's the case like let's all band together and help our fellow citizens who need this help. And so like that's what I wanted to do with the article is kind of just try to encourage people to think like oh, there are these people in these situations that need help and they may not need help forever,

but they need help now and like if we want a healthy, economically strong state, like that's what we can all work to do so that is to do this thing so anyway well thank you so much I want to be respectful of you guys' time so is there anything that we don't get to that you want to put in at the end and can you also give me the links to those organizations so that I can put those in the show notes and anything else that people might want to check out after listening to this Yeah, I definitely can um I um, I can Oh, sorry, I can put those Um, then you don't have to do it now

Just I want to make sure listeners know that they can get more information about that if they if they're interested Yeah, alabama rise is great They do a really good job of keeping everyone informed and up to date on what those do a really good job of keeping everyone informed and up to date on what those core issues are that are currently happening and when to lobby and who to talk to and when to show up at the State House and all those things. So they really are doing a lot of the work that I think a lot of people don't want when they're like, oh, I don't want to get involved that because I don't know how they do a lot of the how and really support you and being able to you know, really Actively engage in a political way. That's meaningful

Anything we don't get to that you feel like is is information that is relevant and it needs to needs to be included Yeah, I just would like get back to like encouraging people to not be hopeless about Politics and to kind of just say like, yeah, Alabama, rise or Alabama, Appleseed, just learning about learning about bills that are in the state house, calling your state legislators, that feels really good to be civically active and you can, you know, turn the needle. So there was just a law about age of parental consent for teens receiving healthcare services. And it was going to go from 14 to 18, which would have been challenging for a lot of teens who are going to the doctor alone because they can drive or they have a grandparent

who's more involved in their care and that they're not the legal guardian. And through a lot of advocacy, that law was brought down from 18 to 16, which is good. So that they cannot impede access to care for teens. So that's just an example, like there was advocacy surrounding that in the medical community and that was changed. So like you can make a difference with issues that matter to you,

not these huge issues, probably like private insurance, but smaller ones that are also important. So I would just encourage people to not be helpless and to get engaged with more local or more state-based organizations. Yeah, and I think too, one of the reasons I wanted to celebrate your article and say thank you is a lot of times there's a culture in medicine

with medical doctors where they don't wanna break ranks. And I understand like a lot of the reasons why they don't because there's a lot of times there's a culture in medicine with medical doctors where they don't want to break ranks. And I understand like a lot of the reasons why they don't because there's a ton of liability in basically criticizing your colleagues or saying different things. But it contributes to that problem of people being hostile to doctors and people not understanding,

because the person at the top of the private insurance company that's rejecting the thing ultimately has a medical degree. And when the doctors who are in it for the right reasons don't criticize that because of a fear of liability and the same reasons a lot of people don't speak out, I think it reinforces that problem. And to kind of have these conversations

and be open and honest about an economy of ideas and to be able to kind of have free discussion and debate around these things is important. It's important for medical professionals to say these things. And not just after you've gone on NPR and written a book and you have millions of dollars and it doesn't matter at the beginning of your career,

the middle of your career. So we really appreciate what you did and what you continue to do. Thank you. Yeah, I think I just, I want my patients to know that I care for them. I think they do know that. We really appreciate what you did and what you continue to do. Thank you. Yeah, I think I just I want my patients to know that I care for them. I think they do know that and but that most doctors do care a lot for their patients. And but yeah, I think sometimes there's a fear of speaking out and you know, I guess

you could fire me, but I could be a primary care is in demand. I think I'm somewhere else. But I I don't think they will. But yeah, I think it's important for patients to know what we're going through too, and that there are barriers. And a lot of patients, a lot of doctors burn out and then go work for United Healthcare, which is the largest employer of doctors in the country. And it's so sad. So whenever I end a peer to peer with them, I always say egg, you know. Yeah, whenever I end a peer to peer with them, I always say, I hope you appreciate that what you're doing

is contributing to burnout for doctors like me who are actually caring for patients. And like, I hope you feel bad about that. And that's how I end my period of period of perioders. And if that makes you feel good, that's like a little thing that I can do. Yeah. I was on the phone with somebody, my wife cleared at me,

but I was on the phone with somebody with a tech support bureaucracy thing, and I was explaining something to them, and they were like, what do you want? And I was like, I just want you to feel bad. What? Yeah. Yeah, no, I know, I just, yeah, yeah.

When retired doctors do that, it kills me. I'm just like, what the heck? Like, you should find some other side gig like driving for Uber or something. Like, that's not what I'm doing. Well, thank you so much for coming on. This was a joy. Hopefully we can do this again around other topics. We were hoping to have the podcast studio by this point, but connecting visually works pretty well. So hopefully we can do kind of more local issues and local guests. And we really appreciate your work. You can find out more information about Haley and her practice on the TapRite website. And then we will link to everything that Dr. Echenrod mentioned and then also her practice page in the show notes too, if you all

want to check that out. The next podcast will be a guided meditation on anger, no relationship between the content here and completely random series of so enjoy that and we will hopefully talk to you again soon. Thank you so much. It was really fun to talk to you both and have a good rest of your day. Music Good morning my darling, I've been telling you this To let you know I'm sorry you're sick Tears of sorrow won't do you no good I'd be your doctor if only I could You can be sure you won't do you no good I'll be your doctor if only I could

You can be sure you won't suffer alone I'd swim the ocean so the deepest canal To get to you darling just to make sure you're well There's no place on earth that I won't hasten to go To cool the fever this I want you to know