Can Republicans wreck Medicaid through block grants?

A brilliant article–by me–covers much wrong with Medicaid block grants:

Every politician knows that you can’t touch Medicare without first gaining the permission of America’s seniors. Yet Republicans now seek to upend the basic structure of Medicaid, with surprisingly little discussion, let alone any effort to determine how low-income adults and children, the aged, and the disabled feel about these critical changes to their health coverage.

This battle doesn’t get the political attention it deserves because the details become boring and technical, and because the design of Medicaid apparently affects other people – by which we mean poor people – who presumably should be grateful for what they get.

Speaker of the House Paul Ryan and others would convert Medicaid to a block grant. Before inauguration, President-elect Trump announced his support for this approach. Rep. Tom Price, the Trump Administration’s nominee to run the Department of Health and Human Services, reiterated that position in his confirmation hearings.

On last Sunday’s talk shows, White House counselor Kellyanne Conway suggested that converting Medicaid to a block grant would ensure that “those who are closest to the people in need will be administering” the program.

As with everything in Trump-era health policy, we haven’t seen the fine print. We don’t know how the block grants would be financed, how they would impact states or low-income citizens. The details matter, and they won’t be good….

More here, at

Unrelated picture below:

Continue reading “Can Republicans wreck Medicaid through block grants?”

“Transcending Obamacare”–A conversation with Avik Roy

Given the fact that conservative health policy advisor Avik Roy and I have disagreed so vehemently and so often, RBC readers might be surprised by the civil conversation we conducted over at about Roy’s new health plan.

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I hope my fellow liberals will read what he has to say–not because you will agree with him, but because he offers an instructive and well-articulated vision of what conservative health policies might look like that build on the platform created in ACA. I am a firm believer in Mill’s idea that if you only know your own side of the argument, you really don’t know that.

Roy rightly acknowledges that Republicans will not outright destroy ACA at this point. That question was decided by the 2012 election and by the (eventually) successful roll-out of ACA this year. Whatever the polling numbers on “Obamacare,”  the on-the-ground progress is impressive. Medicaid expansion and the new marketplaces are embedding within the fabric of American life.

Where it gets interesting and disconcerting is to note the generative conservative possibilities opened up by ACA. Roy would limit ACA in various ways. But his real quarrel is with Lyndon Johnson not Barack Obama. Once 64-year-olds are enrolled in the health insurance marketplaces, why the abrupt transition at age 65? Roy would raise the Medicare eligibility age by four months every year, retaining the subsidy structures provided by the exchanges and Medicaid. Over time, this would turn Medicare into much more of a means-tested program with dramatically reduced actuarial subsidies to the top half of the income distribution.

I don’t support this or see it as politically attractive for Republicans. But Roy’s plan raises fundamental questions about what we want Medicare to be and do.  More here.

If you like your reduced ER use, you can keep it

IMG_1553The latest results are in from the great Oregon Health Insurance Experiment (OHIE).

In a randomized experiment, individuals offered Medicaid coverage showed higher rates of emergency department (ED) use than did their otherwise comparable peers not given the same opportunity.

The effect size was pretty small—about one extra ED visit per recipient, every 3.5 years or so. In dollar terms, this amounts to an estimated annual expenditure increase of something like $120 per recipient. We can’t say from this paper whether the extra ED visits were valuable or cost-effective. We can say that these results will embarrass some liberal advocates who argued that expanded coverage would reduce overall rates of ED use.

They should. This talking point was never properly evidence-based or even particularly plausible given prior research. It’s not obvious that reducing the rate of ED use is even a sensible policy goal. Advocates across the political spectrum should stop using the ED for cheap talking points about the mythical savings associated with universal coverage or about the misbehavior of Medicaid recipients who supposedly waste huge amounts of money through overuse.

We might, instead, take some satisfaction that we have created a system, open 24 hours per day, 365 days per year, which people turn to when they need help. Our challenge is to make this system work.

More here.

ACA redistribution via Medicaid: what it means for future reform

The self imposed redistribution from mostly poor (mostly red) states, to mostly rich (mostly blue) states via the ACA Medicaid expansion is a direct result of the June 2012 Supreme Court ruling that made it voluntary.

That 7-2 court decision, and the subsequent state decisions, mean that the primary liberal/progressive health reform goal of expanding insurance coverage is being thwarted in some of the most needy states. Liberals/progressives have two choices: fight out the state-by-state Medicaid expansion decisions, or seek a health reform deal with conservatives that would be more likely to expand coverage in the non-expanding, poorest states, sooner. The first is not a pleasing outcome, and the second seems like a political impossibility. Continue reading “ACA redistribution via Medicaid: what it means for future reform”

ACA: self imposed redistribution from poor to rich states

At present, 24 States (and DC) have decided to move ahead with the Medicaid expansion provided for in Obamacare, and 21 have rejected expansion, while 6 are still considering their options. If the current decisions hold, it will result in a self-imposed redistribution of money from poorer (and typically Red states), to richer (and typically Blue ones).

According to an analysis I have done using Kaiser Family Foundation data–in 2016 alone–the 24 expanding states will receive $30.3 Billion additional federal dollars, while those not expanding will forego an additional $35.0 Billion they could have had (the fence sitters have an aggregate $15.2 Billion at stake in 2016). This represents a huge redistribution of federal money from non-expanding to expanding states. The table below highlights the biggest self imposed losers, and winners, again for 2016 alone (there are predictable impacts on state uninsured rates).

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Note: total is for all states in foregoing & gaining group.

Continue reading “ACA: self imposed redistribution from poor to rich states”

New Class: Future of Medicaid in North Carolina: Charge & Questions

I am very excited to be teaching a new Masters of Public Policy course this Fall at Duke University on The Future of Medicaid in North Carolina. The 14 students all have background in health policy, including prior job, coursework and recently completed internships.

The charge to this class is going to begin with the charge that the recently passed North Carolina budget gives to a new Medicaid Reform Advisory Group ( p. 161-62): Continue reading “New Class: Future of Medicaid in North Carolina: Charge & Questions”

The math of Medicaid expansion in North Carolina

To summarize yesterday’s post, if North Carolina undertook the Medicaid expansion, the impact on State expenditures from 2013-2022 would be (based on KFF/Urban Institute study):

  • Reduce State spending on uncompensated care by $1.350 Billion (cumulative savings over 10 years)
  • Increase State spending via North Carolina’s share of the expansion by $3.075 Billion (cumulative, 10 years).
  • This is a net increase in State spending of $1.725 Billion over the 10 years

A key policy question is always is the net increase in State spending worth it?

Continue reading “The math of Medicaid expansion in North Carolina”

The (Portland) Oregon Medicaid Study

A new study today on the Oregon Medicaid experiment (they randomly selected some who applied for coverage while denying others; the difference in the groups is the estimated impact of having Medicaid v. being uninsured in Portland, Oregon; they data reported are only from Portland, and not statewide). Such a study design is as good as it gets on internal validity (does x cause y; in this case does Medicaid make people healthier, measured in a variety of ways, as compared to being uninsured). The external validity of such a study–are these findings applicable to other places depends upon how similar other states are to this study population (Portland).

Based on reading the many tweets this afternoon about the study, I was surprised when I actually read the study. Basically, they find that Medicaid coverage: Continue reading “The (Portland) Oregon Medicaid Study”

Cherry Picking in Medicaid

Managed care companies are cherry picking the healthiest disabled senior dual eligible beneficiaries in New York state using a variety of methods, and excluding those needing the most care. The program provides a monthly per capita payment amount ($3,800/month) regardless of how much care is provided. The general theory is that the insurer has an incentive to keep people well, reducing care needed, and therefore increasing their profit. However, there is also an obvious financial incentive to simply sign up those who need less care in the first place. Several points here. Continue reading “Cherry Picking in Medicaid”

Preventing crimes by mentally ill offenders: The role of health reform

We can’t specifically predict atrocities such as occurred in Sandy Hook. Yet the Medicaid expansion in health reform is an important step in addressing violence by mentally-ill offenders.

Me with a long piece in the Washington Monthly:

It’s a strange thing. Newtown was an atypical crime, committed by an atypical offender, using a murder weapon that I hope will be outlawed but that remains pretty atypical for gun homicides. Even though we may not be able to stop an event like Newtown from happening again, it seems to be moving public policy more than the routine smaller scale tragedies that we could more easily prevent. Newtown has provided a genuine occasion for Americans to think seriously about gun policy, and to consider the very real challenges to our mental health system. We should make the most of this moment.

It’s naive to believe that we could specifically identify someone such as Adam Lanza before he goes on a rampage, but improved policies could still prevent an unknown, maybe unknowable number of violent deaths. No one policy will dramatically reduce homicides, and the politics and administration of effective mental health policy are both daunting. But making these policies work would provide a fitting memorial to the victims of needless violence across America. While we may not be able to entirely solve the tragedies that occur at the intersection of mental illness and gun violence, surely we can do better than we’re doing now.

More here.