“Saving That ‘Worthless’ Medicaid”: The Idea Of ‘Worthless’ Is Correlated To The Idea Of The Life Of Poor Folks Being ‘Worthless’
As noted earlier today, it’s the 50th anniversary of the enactment of Medicare and Medicaid.
I strongly suspect the former will get more attention, because it’s a non-means tested program with an extremely powerful bipartisan constituency (despite constant GOP efforts to screw over future beneficiaries via a phased-in voucherization or some other way to shift costs to old folks). Everybody’s either on it or going to go on it if they live long enough.
Medicaid’s another matter, of course. It’s means-tested with the states having significant control over eligibility and benefits, which means it involves different sets of people (particularly now that half the states have accepted the ACA’s Medicaid expansion while half haven’t) and significantly different benefits and service delivery models in different states. With the exception of a little-understood long-term care component that pays for nursing home care for people who have disposed of most of their assets, Medicaid is a poor folks program–you know, for those people–which because it is state (and to some extent locally) operated means these poor folks are not necessarily dealing with the friendliest policy-makers, administrators or providers, particularly given Medicaid’s relatively low reimbursement rates.
But to the Republicans who have all pretty much agreed upon a policy of “block-granting” Medicaid, which means dumping the Medicaid population on the states with a fixed (and ultimately declining) sum of money and letting them do whatever they want to do with them, the question about Medicaid isn’t whether its structure and financing are giving the poor the kind of health care the rest of us would want, but instead whether it’s worth anything at all. That’s largely the function of prejudice plus a 2013 study in Oregon of people receiving and not receiving Medicaid benefits which provided some startling-sounding data on how little real benefit Medicaid created. It’s hard to read any conservative discussion of Medicaid and not hear the Oregon study “proved” Medicaid’s worthless.
So that’s why with Medicaid’s fate perhaps hanging in the balance after the upcoming election, three excellent policy writers, Harold Pollack, Bill Gardner and Timothy Just, have written an explanation of the Oregon study that rebuts its invidious use.
[P]erhaps the most important limitation of the study stems from an assumption that many readers would be unlikely to notice. [The Oregon researchers] placed a very low value—$25,000—on a year of additional life for Medicaid beneficiaries. The typical threshold used in health services research is much larger, in recent studies far above $100,000 per additional year of (healthy) life. Yet because the median income of the Oregon study participants was about one-fourth of the median income in the United States, the researchers chose to value an additional life-year at about one-fourth of the usual threshold. This assumption powerfully frames everything that follows in this analysis. After all, if you start out by assuming that Medicaid beneficiaries’ lives are worth very little, you will find that it is not worth spending much money to prolong them.
So the idea of Medicaid being “worthless” is closely correlated with the idea of the life of poor folks being relatively “worthless” (there are defensible reasons for this valuation in the study itself, but not for the way it’s being used by anti-Medicaid ax-grinders) as well. If you don’t share that premise, you shouldn’t share the related conclusion, either.
In any event, progressives should gird up their loins for a fight to save Medicaid in the near future. I’ve thought of myself as a warrior for the continuation of Medicaid ever since I was drawn into the 1981 Reagan Budget fight, wherein the administration suffered a rare defeat in its efforts to “cap” federal Medicaid spending, thus gradually making it a state-financed program. The fight just ahead could be even tougher.
By: Ed Kilgore, Contributing Writer, Political Animal Blog, The Washington Monthly, July 30, 2015
“In Addition To Honesty, It Requires Accountability”: Ryan Unsuited To Lead ‘Adult Conversation’ About Poverty
These days, a favorite talking point of Republican Congressman Paul Ryan’s is calling for an “adult conversation” about poverty.
“It’s time for an adult conversation,” he told The Washington Post.
“If we actually have an adult conversation,” he said in remarks at the Brookings Institution, “I think we can make a difference.”
The problem is that a prerequisite for any adult conversation is telling the truth and it is there the congressman falls monumentally short.
In addition to Rep. Ryan’s recent, racially-coded comments about “our inner cities” where “generations of men [are] not even thinking about working,” his rhetoric around policy should raise red flags for anyone — including the media — assessing his credibility.
A report from Emily Oshima Lee, policy analyst at the Center for American Progress Action Fund, examines the hatchet job Rep. Ryan did on Medicaid in his 204-page account of antipoverty programs that The Washington Post generously described as a “critique.” Indeed, Ryan’s report — which would have been flagged by my excellent 10th grade English teacher for misrepresenting and cherry-picking data — is a dangerous disservice to a public which has neither the time nor the staff that Ryan has at his disposal to delve into literature assessing antipoverty programs.
Lee notes that Ryan misuses research to imply that Medicaid coverage leads to poorer health — that people enrolled in Medicaid will have worse health than those with private insurance and the uninsured.
“The privately insured comparison is patently unfair because these people tend to be higher income and that comes with a whole host of health privileges,” said Lee.
She notes that Medicaid enrollees tend to struggle a lot more with chronic conditions and illnesses than other populations.
“A large body of literature identifies various social determinants of health, including socioeconomic status and living and work environments, as risk factors for poor health outcomes,” writes Lee, in my opinion admirably resisting the temptation to add, “duh.”
As for the uninsured being healthier — it would be one thing if Ryan were making an “apples to apples” comparison, but he’s not.
“The uninsured is a diverse group and doesn’t only include low-income individuals. It may include people who are high-income and don’t really want insurance but can afford health services, and lower-income people who may not have previously enrolled in insurance for a number of reasons — including cost and not having any real health issues,” Lee says. “But again, to imply that Medicaid is somehow making people worse off is absurd.”
Ryan also argues that Medicaid coverage has little positive effect on enrollees’ health. But as Lee points out, Ryan conveniently overlooks studies showing an association between Medicaid and lower mortality rates; reduced low-weight births and infant and child mortality; and lower mortality for HIV-positive patients, among other heath benefits.
“In general, we need more data to accurately assess the effect of Medicaid coverage on people’s health,” Lee continues. “But several studies do indicate positive health and non-health effects of coverage — such as increased use of preventive care and greater financial security.”
Rep. Ryan also plays on fears of low-income people abusing the welfare system when he asserts that Medicaid coverage improperly increases enrollees’ use of health care services, including preventive care and emergency department services. Ryan makes this case too by comparing Medicaid enrollees to uninsured people, who, as Lee writes, “are less likely to use health care services due to significant financial barriers.”
“Presenting data that Medicaid enrollees use more health services than the uninsured affirms that insurance coverage allows people who need care to seek it out,” writes Lee, “and that being uninsured is a major barrier to receiving important medical care.”
Further, one of the two studies Ryan references explicitly states that “neither theory nor existing evidence provides a definitive answer to… whether we should expect increases or decreases in emergency-department use when Medicaid expands.”
Despite Ryan’s shabby work when it comes to antipoverty policy, the media repeatedly seems willing to overlook it. That’s another strike against the prospects of a truly adult conversation about poverty — in addition to honesty, it requires accountability.
By: Greg Kaufmann, Moyers and Company, Bill Moyers Blog, March 29, 2014
“Ideology Versus Pragmatism”: Republicans Consider Stripping Health Insurance From Tens Of Thousands Of Arkansans
In Arkansas, approximately 83,000 low-income residents are in danger of losing their health insurance as early as July 1.
In 2013, Arkansas’ Republican-controlled legislature devised an alternative plan to expand Medicaid while still protecting the state’s poorest residents and hospitals. Through the plan, commonly referred to as the “private option,” Arkansas distributes federal funds — provided under the Affordable Care Act — to eligible recipients, who then use the funds to buy private health insurance plans. Proponents note that the plan offers private coverage to residents who would otherwise be unable to obtain it.
As The Washington Post reports, Governor Mike Beebe (R) welcomed the plan, saying it would save taxpayers nearly $90 million this year. The Obama administration later approved the plan, adding two necessary conditions: that cost-sharing and recipients’ benefits remain the same as the traditional Medicaid program, and that the total costs of the private plan do not exceed those of implementing traditional Medicaid expansion.
Over the past year, the private option has become so popular that variations of it are now being adopted in several states, like Pennsylvania and Utah.
“In crafting the ‘private option,’ Arkansas has provided a pathway for other states. They truly are trailblazers,” Deborah Bachrach, a partner with consulting firm Manatt Health, told the Post.
In recent weeks, however, Republicans have threatened to jump ship on the plan, jeopardizing the program that offers protection to tens of thousands of Arkansans.
With the state’s May primaries quickly approaching, Republican lawmakers facing more conservative challengers are feeling the pressure to vote against a renewal of the program’s financing.
“You’ve got a very small minority of people who can derail this,” explains Governor Beebe, who says that the sudden lack of support has to do with “ideology versus pragmatism.”
“If we lose one or two votes, it’s critical,” he added.
Considering that Arkansas requires 75 percent of the members of both houses to pass appropriations measures, “one or two” GOP votes are certainly critical to the program’s future. And in recent weeks, two Republican state senators have voiced their opposition to extending the private plan.
Senator Missy Irvin, who voted for the program last year, announced she would no longer support it, citing a decision made by Arkansas Blue Cross and Blue Shield – Arkansas’ dominant health insurance company – to cut reimbursement rates by 15 percent to specialists who participate in its federally run online insurance exchange plans. Irvin might have had another motive, however; she is currently facing a primary challenge from Tea Party candidate Phil Grace, who pointed to Irvin’s support for the private option as one of the main reasons he chose to run.
The argument against the plan made by Grace and other conservatives like him is rather vague, but it still has the power to sway other GOP votes.
“Right now, Washington is broken and trillions of dollars in debt. We can’t count on D.C. to keep promises for any funding and Arkansas certainly can’t foot the bill. The only way to deal with D.C.’s issues is for states to band together and push back,” Grace says.
Grace’s opposition to the private program – which has been echoed by other conservatives running in 2014 — steers clear of the GOP’s typical “big government” arguments, leaving it seeming rather arbitrary.
State Senator John Cooper, another Tea Party favorite, also says that he will not vote to reauthorize the plan’s funding — which is not a surprise, since he won the state’s special election by running against the program. Cooper argues that it will not save Arkansas money in the long term, despite reports to the contrary.
If Republicans vote against the private option – a vote that come could as early as next week – the implications for the state’s poor residents are burdensome and great. Before the private option existed, Arkansas had one of the most restrictive Medicaid programs in the nation, which made it especially difficult for struggling individuals and families to obtain coverage.
By: Elissa Gomez, The National Memo, February 11, 2014
“Medicaid Matters”: Where Is The Outrage Over GOP Governors Cutting Off Lower-Income Americans From Access To Medicaid
E.J. Dionne Jr. raises an argument in his column this morning that’s been getting short shrift by too much of the political world lately: Medicaid expansion matters, and far too many state Republican policymakers are blocking it for no reason.
“President Obama apologized last week after all the criticisms of what’s happening in the individual insurance market,” Dionne explained. “But where is the outrage over governors and legislators flatly cutting off so many lower-income Americans from access to Medicaid? The Urban Institute estimates that 6 million to 7 million people will be deprived of coverage in states that are refusing to accept the expansion.”
The recent disruption in the health care marketplace certainly matters, and the Obama administration has a lot of work to do to put things right. But if we’re going to talk about policymakers who need to apologize and show some semblance of regret, can we at least start to have a conversation about those keeping millions of struggling Americans from having access to coverage, largely out of partisan spite?
Jonathan Cohn published a good piece on this earlier:
Today it’s a few hundred thousand people. By next year, it will be at least a few million. Their health insurance status is changing dramatically: What they have in 2014 and beyond will look nothing like what they had in 2013 and before. For many of these people, the difference will be hundreds or even thousands of dollars a year. In a few cases, it may be the difference between life and death.
You probably think I’m talking about the people getting cancellation notices about their private insurance policies. I’m not. I’m talking about the people getting Medicaid. Both stories are consequences of the Affordable Care Act. But one is getting way, way more attention than the other.
There’s been an obvious preoccupation – on Capitol Hill, with Beltway media, etc. – with website dysfunction and cancelation notices, while Medicaid expansion, which arguably affects a larger group of people, has been routinely overlooked.
Maybe it’s because Washington is “wired” for Republicans and it’s the right’s complaints that have been driving the recent conversation. Perhaps it’s the result of Medicaid beneficiaries lacking the kind of political capital that keeps their plight on the political world’s front-burner. Maybe it’s a matter of timeliness, with implementation disruption seeming “new” in ways Medicaid is not. Perhaps it’s a combination of things.
Regardless, by my standards, this is a genuine scandal. The administration’s missteps are real, but they’re not deliberate. “Red” states rejecting Medicaid expansion because of some misguided contempt for “Obamacare” are leaving struggling families behind on purpose. The callousness is outrageous.
Cohn concluded, “”Should the president have been more candid about the impact his plan would have on people buying their own coverage? Yes. Should we pay attention to those people, particularly when they must now pay more for equivalent coverage? Definitely. Should this put extra pressure on the administration and some states to fix their websites? You bet. But that’s not the only Obamacare news right now. The law is making life better for a great many people – and would help even more if only Republican lawmakers would relent.”
By: Steve Benen, The Maddow Blog, November 11, 2013
“Let’s Take A Step Back”: Despite Crappy Journalism, Things That Are Still True About Health Care
It’s been a pretty intense month on the health-care front, what with the beginning of open enrollment for the new exchanges giving rise to lots of disingenuous fulminating from Republicans, not to mention a whole lot of crappy journalism. Any time a story dominates the news for a couple of weeks, there’s a temptation to believe that what’s happening now will change everything. So I thought it might be a good idea to take a step back and remind ourselves about some things that are still true about the Affordable Care Act and still true about health care in America.
Over the long term, the problems with Healthcare.gov won’t have much of an effect on the success or failure of the law.
Yes, it has been a huge screw-up, with both the administration and the contractors sharing responsibility. Yes, it has caused a lot of people trying to sign up for new insurance a lot of hassle. But it’s the thing everybody’s focused on now in part because it’s the only thing happening with the law, until January 1st when a whole bunch of the law’s other provisions also go into effect. The problems with the web site are finite and fixable, and five years from now all this will seem like a minor footnote in the whole story.
Even if everything works perfectly with the ACA, we’re going to have a very expensive system for a long time.
The law did many things to try to “bend the cost curve,” including things like rewarding hospitals for reducing their readmission rates so there isn’t such an incentive to just pile on the procedures. But the fundamental fact is that America’s health-care system is far and away the most expensive in the world—nearly twice as expensive as the average for OECD countries—and it will still be very expensive for the foreseeable future.
There are many reasons why, but what they come down to is that there are lots of actors—insurance companies, hospitals, doctors, device makers—who make ungodly amounts of money off our health-care system, and unwinding all their influence and the points at which costs get driven up is unfathomably complicated. Other countries’ systems were designed by asking how good care can be delivered to everyone at a cost the country can afford; our system, outside of the government parts like Medicare, was basically designed by asking how to make sure everybody except patients can make as much money as possible. At its heart, the ACA doesn’t question that fundamental premise. So the curve may bend, but it won’t bend too sharply, and it’s starting from a very high place.
The expansion of Medicaid is the most significant thing the law did to help uninsured Americans.
It’s easy to forget, with all this talk about people on the individual insurance market, that they make up a small portion of the country. The most meaningful part of the ACA was always its expansion of Medicaid, promising to finally give insurance to millions of Americans who can’t afford it. So far, people signing up for Medicaid are significantly outnumbering those signing up for new private insurance, which isn’t surprising, especially given Healthcare.gov’s problems. And every time a poor family signs up for Medicaid, it’s cause for celebration—they’ll be healthier and more secure, they’ll be more productive at work, and the whole community benefits.
The Republican sabotage campaign against the ACA is unprecedented in American history. You can’t blame every problem the law has or will have on Republican sabotage, but this isn’t hyperbole. It truly is something we’ve never seen (here’s a recap). The only thing that comes close is efforts in the South to resist the school desegregation mandated by Brown v. Board of Education. That isn’t an excuse for any failures of the Obama administration, but it has made everything harder.
Republicans criticizing the ACA have no idea what they’d do to improve the health-care system. If you ask them, they’ll say, “Um … tort reform?” There are a very small number of conservative health-care wonks out there (like the people who came up with the plan that became Romneycare which became Obamacare!), but their ideas are laughably small-bore. Republicans are essentially satisfied with the pre-ACA status quo, with 50 million uninsured Americans and skyrocketing costs. That doesn’t necessarily mean that any particular critique they make of the ACA is wrong by definition, but it’s good to keep in mind.
There’s still no good reason your job should determine your health coverage. The linking of health insurance and employment is an historical accident. When wages were frozen in World War II, companies began offering insurance as a way to attract better workers, unions began demanding it as part of contracts, and today around 80 percent of American get their coverage through their job. One of the best things the ACA does is eliminate the “job lock” this produces, by making it illegal for insurance companies to deny coverage based on pre-existing conditions. Now you can quit your job to start that business you’ve dreamed of without worrying about whether you can get insurance. But the link between employment and insurance is just one more layer of complication that makes our health care system such an absurd kludge. Which leads to…
A single-payer-plus system would have made this whole thing simpler. Conservatives may roll their eyes and say, “Are you still going on about that?” but it’s something we should indeed keep talking about. The Affordable Care Act brings us to a system that is much better than what we have now, but still far worse than what it could be. I’ll continue to reiterate that we could have a system that satisfies the desires of both liberals and conservatives, insures everyone, and does it without all the layers of complication we suffer through now. If we wanted to, we could transition over time to a system like they have in France, with a basic, government-provided single-payer plan that covers every citizen, combined with a market for supplemental private insurance. That would give us the universal coverage and security liberals like, the ability to buy as much insurance as you want from a private company that conservatives like, and the efficiency and cost savings we all ought to like.
Would that be a big change? Sure. But it’s essentially what America’s seniors already have, and it has been very successful. They have their government plan so there are virtually no uninsured seniors, and they can buy Medigap coverage to give them extra benefits.
The ACA could make it easier to transition to a system where all Americans enjoy the same privilege. The exchange marketplace could be transitioned to become the place everyone buys supplemental insurance. We now have a system where a significant chunk of the population—the elderly and poor—are on government plans, and you could widen their availability in both directions (down in age and up in income) and unify the benefits.
That’s a long-term project, but it could be the next big health-care reform (in 20 years or so). Obviously, the most important priority in the next year or two is implementing the ACA and determining what’s working and what isn’t so it can be tweaked and improved. But we shouldn’t forget about what comes next.
By: Paul Waldman, Contributing Editor, The American Prospect, November 1, 2013
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