North Carolina Senate Budget on Medicaid

The N.C. Senate released its budget, and the key Medicaid section starts on page 91. A few highlights and some questions and comments:

  • Section 12H.1.(b) stops the movement toward a regionalized “Medicaid ACO reform approach” that was the direction that the Executive branch (NC DHHS) had been moving, and is really back toward the Governors initial plan, which I labelled as ‘unworkable’. But, the phrasing below about full-risk capitated plans and provider led and non provider led plans is quite vague, so might really encompass Medicaid ACOs. I don’t know if the language is trying to be coy, or if they don’t really appreciate the nuance under the labels.
  • Section 12H.1.(a) would move Medicaid out of NC DHHS and into an independent agency (first sentence below). The execution of such a move is key, but I actually think this is a pretty good idea.
  • Section 12H.1.(a) also has some generalities that are difficult to judge without lots more details. There is *massive* amounts of health policy in lines 16-21

SECTION 12H.1 .(a)It is the intent of the General Assembly to transfer the
14 Medicaid and NC Health Choice programs to a new state entity that will define a new, more
15 successful direction for the programs and that will be able to focus more clearly on the
16 operation of the programs. Specifically, the Medicaid program shall move away from
17 unmanaged fee -for-service towards a system that manages care. To that end, Medicaid shall
18 include all dimensions of care for a recipient through full-risk, provider-led and
19 non-provider-led, capitated health plans. Such full-risk capitated health plans shall include all
20 aspects of care, without exceptions, so that the State will bear only the risk of enrollment
21 numbers and enrollment mix

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What makes reducing the ranks of the uninsured worth it?

The debate about whether health insurance improves health has been ushered into prominence by the need of proponents and detractors of the ACA to make their case against the other side. It is an important discussion, regardless of why is has popped up (examples of good debate: one | two). Much of the best debate has been technical in nature, hinging on issues of research design, internal versus external validity, statistical power and the choice of measures. The latest round of skirmishes has ventured into the area of whether the benefits outweigh the costs, always a fair question in public policy as is seeking to fully identify the costs and benefits.

This morning I did something I may not have done since I graduated with my PhD 19 Mays ago–I read some of my dissertation “Alternative Measures of Medical Underservice: A Proposal and Assessment.” Continue Reading…

ACA enrollment milestone

Midnight was the enrollment deadline, but people who were in process with applications can complete the process through the first two weeks of April. This is a big milestone in the law, but no matter how much everyone wants an instant assessment of the ACA as “working great” or “sucking” that answer is not forthcoming based on how many signed up. I will, however, go out on a limb and predict the answer is somewhere between “working great” and “sucking”.

Here is what I will look for over the next 6 months: Continue Reading…

Concurrent Hospice Demonstration Announced

Yesterday, CMS announced a concurrent hospice demonstration that will begin this Summer in the Medicare program. 30 hospices will be allowed to begin the 3 year pilot, and must apply by summer 2014 to do so. The so-called Medicare Care Choices Model will allow hospices to provide care to Medicare beneficiaries without their having to “unelect” curative care first (they must do so now under the hospice benefit). Continue Reading…

Why I didn’t blog about the House Poverty report

A few people have asked why I didn’t blog about the release of Rep Ryan’s House Budget Committee poverty report that came out on Monday. I did tweet this Monday:

and this

I didn’t blog about it because the Medicaid portion of the document is really quite bad given that the report was hyped as the precursor to a major policy push by Rep Ryan and House Republicans. It is essentially a poorly done annotated bibliography that would get about a C- in my intro U.S. health system course. The biggest problem with the Medicaid portion of the document is not even the one-sided summary of the literature that is cited that could be forgiven in such a document, but ignoring the issue of the dual eligibles almost completely in something that is meant to set up the need for Medicaid reform is quite a big miss. So, the document is not serious enough on the Medicaid issue to warrant much blogging time.

I didn’t read the remainder of the report (on other federal poverty programs) after looking at the Medicaid parts. Here is a blog tag on the many things I have written about the dual eligibles and the need for reform.

cross posted at freeforall

Employment, Health Insurance and Means Testing

The CBO Budget Outlook (2014-24) is out today, and much of the focus is on their revised estimate of the ACA’s impact on the labor market (Appendix C, pp. 118-27). CBO is projecting that “the ACA will cause a reduction of roughly 1 percent in aggregate labor compensation over the 2017-2024 period, compared with what it would have been otherwise” (p. 117). This is basically CBO’s estimate of the impact of the marginal tax rate on labor income created by the various policy structures of the ACA that Casey Mulligan has written about. As I wrote in this post, you get less of something if you tax it, so if that is not your goal (it is with tobacco taxes, for example) then you are left to decide whether the reduction is worth achieving an alternative goal(s). That can be a difficult question to answer, because you are trading off important things–labor market participation, rates of uninsured, and the system reform provisions of the ACA.

Is reduced labor market participation a sign that we should move away from the structure of the ACA? If yes, to where? Continue Reading…

Still Seeking Clarity on Private Score

I am still seeking to better understand the assumptions of the private score of the health policy proposal put forth by Republican Senators Burr, Coburn and Hatch. Yesterday, around 11:20am EST, I emailed the following addresses at the organization that put out the private score of the PCARE proposal, Center for Health and Economy ( and seeking more information. I have still not gotten a reply. Continue Reading…

Private Score of Senate Republican Health Proposal

Brad Flansbaum sent me a link to a private score of PCARE, the reform plan released on Monday by Republican Sens. Burr, Coburn, and Hatch. I don’t know the Center for Health and the Economy, though I do know several members of their advisory board and many of you will as well. I don’t have my own simulation model to be able to verify these sorts of results, and the CBO is the final word, but I will just assume that a group that has Uwe and Holtz-Eakin on the Board must be somewhat credible. There is much to be learned here, even if you assume this to be an overly optimistic score.

First off, lets just say that the rage machine that has been perfected to argue against the ACA could get plenty cranked up from the these results. There is a breathless Americans for Prosperity Ad running in North Carolina talking about a nice lady losing her doctor in an Obamacare plan, in health policy speak, due to the rise of the narrow network. Yep, this score says PCARE will have a slight increase in persons covered by 2023 compared to the ACA, but most of that arises from a shift of people into narrow network plans. Continue Reading…

Thoughts on Burr, Coburn, Hatch Health Reform Plan

Republican Senators Richard Burr, Tom Coburn and Orrin Hatch released “The Patient Choice, Affordability, Responsibility, and Empowerment Act” today. I am going to call it PCARE. A few quick thoughts/highlights:

  • It acknowledges gravity, while making changes. While PCARE talks of repeal of the ACA, it locks in a good deal of the structure of the ACA, and addresses changes from that new status quo. For example, no lifetime limits (sec 201) is retained from the ACA, as is keeping people up to 26 on their parents health insurance, while the current 3-to-1 age banding premium regulation is replaced with 5-to-1 (now a 64 year old could not be charged more than 3 times what a 20 something could be charged;now they could be charged 5 times as much). Winner 20-somethings, loser 60-somethings. Eventually they say they plan to allow States to set these rules with a looser federal touch, meaning a state could decide to stick with the 3-to-1 premium banding by age, for example. I want to hear more about guaranteed renewability and related insurance market regulations as the 2nd full paragraph of page 2 is a bit slippery. For example, it contains this quote: “Insurance companies would also be banned from making unfair coverage terminations of health coverage.” (emphasis mine). What might “fair” ones be? Continue Reading…

Marginal Labor Income Tax Rates under the ACA

I was a discussant of Casey Mulligan’s paper Average Marginal Labor Income Tax Rates Under the ACA at the UNC Tax Symposium hosted in Chapel Hill, NC by Doug Shackelford this past Saturday. His figure 3 summarizes changes in the marginal tax rate of labor income over the past 7 years, accounting for both explicit and implicit taxes for someone with median wages. For example, in 2014, there is an increase in the marginal rate due to a reduction in work incentive that occurs for someone with median wages because premium subsidies are based on a income-linked sliding schedule–an implicit tax on earning more because you lose insurance subsidy as you earn more income. The paper also identifies increased implicit incentives to work more, for example, the fact that exchange subsidies cannot flow to those below 100% of poverty.

ScreenHunter_01 Jan. 21 16.15

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