How Medicaid expansion could transform health care in Georgia [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

Join us for an insightful conversation with Brendan Pulsifer, a medical student, as we explore the realities of practicing medicine in Georgia, recently ranked as one of the worst states for physicians. We’ll discuss the impacts of limited Medicaid expansion, high rates of uninsurance, and physician burnout on the health care system.

Brendan Pulsifer is a medical student.

He discusses the KevinMD article, “Full Medicaid expansion needed to retain Georgia’s physicians.”

Our presenting sponsor is DAX Copilot by Microsoft.

Do you spend more time on administrative tasks like clinical documentation than you do with patients? You’re not alone. Clinicians report spending up to two hours on administrative tasks for each hour of patient care. Microsoft is committed to helping clinicians restore the balance with DAX Copilot, an AI-powered, voice-enabled solution that automates clinical documentation and workflows.

70 percent of physicians who use DAX Copilot say it improves their work-life balance while reducing feelings of burnout and fatigue. Patients love it too! 93 percent of patients say their physician is more personable and conversational, and 75 percent of physicians say it improves patient experiences.

Help restore your work-life balance with DAX Copilot, your AI assistant for automated clinical documentation and workflows.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://www.kevinmd.com/cme

I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://www.kevinmd.com/learnerplus

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Brendan Pulsifer. He’s a medical student, and today’s KevinMD article is “Full Medicaid expansion needed to retain Georgia’s physicians.” Brendan, welcome to the show.

Brendan Pulsifer: Thanks so much for having me.

Kevin Pho: So you’re a medical student, and you co-wrote this KevinMD article, “Full Medicaid expansion needed to retain Georgia’s physicians.” So tell us, before we talk about the article itself, what led you to write this in the first place?

Brendan Pulsifer: Yeah, so I’m a medical student at Emory University in Atlanta, Georgia, and one of the extracurriculars that I’m in is a club called Health Students Taking Action Together. It’s actually a little more than a club. It’s a nonprofit organization, so it’s its own 501(c)(3), fully separate from the university, and it’s a collection of health profession students throughout the state of Georgia. So there are Emory medical students like me, but there are nursing students, public health students, law students, and they range from schools like Emory, Mercer, GSU. So it really is interdisciplinary and professional students, and our broad goal is to improve the health of Georgians. It’s been around for about twenty to thirty years, and it’s taken many different forms.

So the things that we’re focusing on right now include Medicaid expansion. It’s something that we’ve focused on ever since the Affordable Care Act allowed states to expand Medicaid eligibility to low-income individuals, and Georgia is one of the few states now, I believe there are only nine states, that have not done so. And so one of our advocacy pushes is to try to figure out how we can convince the state of Georgia to allow for more people to be on health insurance through the Medicaid expansion.

Kevin Pho: All right, so go more into detail about that in your KevinMD article for those who didn’t get a chance to read it.

Brendan Pulsifer: Yeah, so we’ve tried a few different ways of advocating for Medicaid expansion. Some of that is direct legislative work; some of that is rallies; some of that is community organizing. What the KevinMD article was focusing on is kind of a mini research study that we did.

So there are a lot of really amazing arguments for why Medicaid should be expanded from the position of the patient. People need health insurance in order to access medical services, and their health outcomes are going to worsen if they don’t have that. That’s been pretty well promoted and documented, and I think it makes a lot of sense. But we are health profession students, and we have a very unique view into not only the patient perspective but also the provider perspective. And there are a few arguments that we think are important and not getting a lot of airtime about why Medicaid should be expanded from the position of the physician.

So we did a survey of, I think we ended up having, a little over 250 medical trainees throughout the state of Georgia. That includes medical students; it includes residents, fellows. It was kind of asking generally about their perception of Georgia’s health care system as well as their future plans, and we got some pretty interesting results. We found that 81 percent of respondents said that Georgia residents do not have access to quality medical care, but a similar number said that our high uninsurance rate contributes to physician burnout, and that around 60 percent of respondents would be more likely to stay in Georgia to practice if there were better options for insurance coverage for patients.

So this kind of highlights the fact that, sure, patients, in order to access care and be healthy, need Medicaid. But if Georgia wants to retain a physician workforce that is competitive, that is numerous, that is able to be in every part of the state and treat its patients adequately, it also needs to consider how Medicaid expansion would encourage people to stay, and what its current system is doing to maybe encourage people to go to other states.

Kevin Pho: So talk more about that link, about uninsured patients potentially leading to physician burnout. What are some of the comments and stories and things that you’ve heard from physicians that really provided context to that link?

Brendan Pulsifer: Yeah, that’s a great question, because I think everyone who does a job likes to feel like they’re good at that job and that the job that they’re doing is good for society, or at least like you’re doing something that makes you feel good at the end of the day. If you’re a mechanic and you’re fixing cars, I think it feels good to know that someone is driving your car out there that you fixed.

But when you’re a physician, let’s say you work at an inpatient hospital. I train at Emory, and so we frequently are at Grady Memorial Hospital, which is a public hospital. I have a patient come in that I’m working with and I’m really trying to help manage. Maybe they have an acute exacerbation of COPD. Maybe they have uncontrolled HIV, and they have opportunistic infections. These individuals, I’m able to help a little bit when they’re in the hospital. But if I discharge them to the street, if I’m not able to provide all of the clinical services that are necessary to fix them, or to at least make them well again, I’m feeling really ineffective. I’m feeling like I’m providing care that ultimately is just going to be undone.

And so I think a lot of physicians want to feel really effective in their role, that they’re able to prescribe a medication, they’re able to do a surgery, they’re able to help someone’s life. And if there are not adequate tools to make sure that that patient is going to have long-term care, chief of which is consistent medical insurance to pay for all of these things that they need, it makes physicians feel burned out. It makes them feel like what they’re doing could be done better elsewhere, which is really unfortunate.

At the same time, because we haven’t expanded Medicaid and there’s such limited access to health care out there, these patients are actually some of the sickest in the U.S. We have more health disparities, I would argue, than many other states. So it’s kind of a twofold problem, where we’re encouraging physicians to practice in other states where they feel like they would be more effective at their job, and that’s also disserving patients who are already experiencing a greater burden because of fewer social supports.

Kevin Pho: So to be clear, you’ve heard of some physicians in Georgia who leave the state, where they cite one of the potential reasons as the lack of Medicare expansion or the fact that the uninsured rate is relatively high?

Brendan Pulsifer: What I can comment on more specifically than that is, you know, the statistics I’m citing to you were Likert scale questions, but we also had kind of open-response questions in the survey we did. And there were many responses where people, trainees, said, “I felt like I couldn’t practice in Georgia because of these conditions,” or, “I’m a medical student, and I’m trying to figure out where I want to do residency. Do I want to do that in an environment that does not help me become an effective physician?”

So it wasn’t necessarily physicians we were hearing from, or rather attending physicians who had finished their training. It was from medical students, residents, fellows who, as they were beginning to think about where do I want to practice, where do I want to train, were considering how their professional life and their effectiveness would map onto those metrics in a different state, in a different locality.

Kevin Pho: So talk about some of the historical context for those who may not be aware of the political context of this decision. What are some of the major reasons why Georgia chose not to expand Medicaid?

Brendan Pulsifer: Medicaid’s been around for decades at this point, and over the years there have been many pushes to kind of expand health insurance to different individuals. I think one of the most notable expansions was the Affordable Care Act, also called Obamacare, which is over ten years old at this point. It doesn’t feel too long ago, but that was able to really open up health insurance for what we call the coverage gap, or people who weren’t poor enough to qualify for Medicaid but also had jobs, or maybe didn’t have jobs, where they weren’t able to get health insurance affordably through the marketplace. And so the Affordable Care Act really tried to target people who were in this area where they weren’t poor enough, but they weren’t rich enough, and it was millions of Americans who have been able to get Medicaid and get affordable care through these services.

However, there was a decision made by the Supreme Court that states would be able to opt into this or opt out of it. So most states in the country at this point have opted into it. I believe the most recent one was North Carolina, and I think that made 41 states or so that have been able to accept the Affordable Care Act’s provisions of expanding coverage. But 9 states, including Georgia and many of its surrounding states, have not opted in. They’ve said, “We’re going to go a different way.”

One of the most interesting policy decisions that’s been made in Georgia recently is, instead of expanding Medicaid, our governor and our legislature have put forward a plan called Pathways, Governor Kemp’s Pathways to Coverage, which was projected to cover about 100,000 Georgians and had work requirements. So it was a bit more stringent than maybe the Affordable Care Act or some Medicaid expansion proposals had been. They did this thinking that it would provide an alternative to Medicaid expansion, but in fact, it hasn’t worked out the way that they had said it would. Despite saying that it would add an additional 100,000 Georgians in its first year, it only added 3,500, so about 3 percent of people they projected to sign up actually ended up signing up, whereas the cost of this, the cost to taxpayers, was $26 million.

So full Medicaid expansion, on the other hand, if they had done it the same year, would have added a projected 350,000 Georgians and would have cut state spending by $710 million. So I think there’s a real resistance in many levels of the government in Georgia to expanding Medicaid, really at the expense of, now we’re seeing, patients, providers, and taxpayers financially.

Kevin Pho: And what do we have to look forward to in the immediate future? Is there consideration about expanding Medicaid in the near future with this legislature?

Brendan Pulsifer: So Georgia’s legislature works three out of twelve months of the year, January through March, so the legislative session for the 2025 year is going to begin in just a few weeks. Every year, as I talk to legislators, it seems like they are getting closer and closer to actually expanding Medicaid. I think we see positive signs. For example, North Carolina is a similarly red-to-purplish state, where you have many Republicans and many Democrats, i.e., many people opposing Medicaid expansion, many people advocating for Medicaid expansion, kind of duking it out in state legislatures, and North Carolina was able to be successful. So I think seeing other conservative-leaning states consider expanding, and actually expanding, gives us hope.

I’ll also note that in the last session, they were able to get the closest, I think, they’ve ever been. They were able to get some of the Republican members to agree to a hearing and actually consider proposals for Medicaid expansion. It required some concessions, and it definitely wasn’t easy, but from what I’m hearing on the Hill, it’s much more likely every year as we go. So I’m not going to say it’s going to happen this year or even next year, but I do think as time goes on, it becomes unavoidable, the cost to physicians, patients, and taxpayers for not expanding Medicaid.

Kevin Pho: And to clarify, when you talk to these legislators, you’re hearing some openness from Republican legislators about potentially expanding Medicaid in the coming years and/or open to negotiation? Is that what I’m hearing?

Brendan Pulsifer: It’s complicated and nuanced. I think many people, regardless of their political party, can recognize the benefits to expanding Medicaid. However, this is a political issue whether we like it or not, and there is a quite united front in the Republican Party to oppose Medicaid expansion. So I actually have heard privately that there are people, Republicans, who understand that Georgia may be better off if we do expand Medicaid. However, for political reasons, I think it’s very challenging for any Republican to go against the status quo, the status quo being, “We can’t expand Medicaid.”

So I think there are people on both sides of the aisle who understand there could be benefits to this, and there are benefits to this. But I’m not sure what a united political opposition will look like in the coming term, in the next term after that, and how that will affect individuals either advocating for, abstaining from, or voting against Medicaid expansion.

Kevin Pho: So I want to ask you about some of your advocacy work. Tell us the difference that medical students and doctors in training, interns and residents, can make in advocating. Is it a hopeless cause? Can we actually move the needle when it comes to changing legislators’ minds? So tell us the influence that you have as a medical student advocate.

Brendan Pulsifer: Yeah, that’s a great question, because I think a lot of medical students I talk to, a lot of trainees, are not fully aware of the impact they can have. And when I say impact, I think a lot of people think it has to be legal; it has to be lawmaking; you have to physically change something like that. But there are so many different ways to be an advocate and to help people, one of which is through a formal legal system, and so we try to do that. My organization, for example, has a long history of going directly to the state Capitol, the Gold Dome, and advocating on the floor of the legislature to speak directly to the people in charge of making laws.

But our organization also has a history of doing a lot of work directly on the ground and community organizing. So I’ll give you an example. One of the programs that we run is called, it’s a program that aims to reduce heart disease among Black Americans. We go into community centers for Black individuals, so that’s churches; it’s barbershops; it’s places where you’re going to find kind of the heart of the community. And we do kind of health screenings. We have a blood pressure cuff, and we have a glucometer, or glucose reader, and we educate about how to prevent heart disease, what heart disease means, if you have an elevated glucose level, what does that mean, when’s the last time you went to a doctor.

So that’s just an example of one of the many ways that we can change the health of Georgians and we can improve people’s lives. Those are just direct things you can do that are very low barrier. You can go into any place, and you can use the training that you have and the tools at your disposal to make a difference. It doesn’t have to be specifically in the legislature, but it can be, and we’re really excited about that kind of multimodal community effort. We have people who are really good at speaking on the floor. We have people who are really good at talking to individuals, especially from marginalized communities. And I think as a medical student, you should feel inspired to choose something that you know you’re good at and run with it and see where you can go.

Kevin Pho: We’re talking to Brendan Pulsifer. He’s a medical student. Today’s KevinMD article is “Full Medicaid expansion needed to retain Georgia’s physicians.” Brendan, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Brendan Pulsifer: Full Medicaid expansion is needed to retain Georgia’s physicians. Georgia’s physicians are considering leaving Georgia. Its trainees are considering leaving Georgia because we’re not expanding Medicaid, and because we’re not treating patients, and the burnout rate is too high when you’re not funding programs that are going to help improve patients’ lives and the jobs of physicians. And medical students have the ability to make a great change in society, no matter what level of training you are at and no matter what your background is.

Kevin Pho: Brendan, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Brendan Pulsifer: Thanks for having me.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes