The premise of my book Balancing the Budget is a Progressive Priority is that the most important long run budget issue is developing a set of health care cost controls that we will actually try. I frame a set of policies that I claim represent what a political deal between Democrats and Republicans would look like to take the next step after the ACA. Arkansas is planning to use Medicaid expansion money to purchase private health insurance in exchanges for low income persons. The details are very important, which are still unclear. However, this is reminiscent (in part) of one of my proposed “next steps” for health reform (p. 64-65 of my book).
Word this morning that Gov. McCrory has decided that North Carolina will have a Federal ACA exchange, and that we will not undertake the Medicaid expansion now. Several quick points:
I had the chance to interview the Urban Institute’s Howard Gleckman, one of the nation’s leading experts on disability policy and long-term care.
I had the chance to interview the Urban Institute’s Howard Gleckman, one of the nation’s leading experts on disability policy and long-term care. The small piece below gives a flavor of things.
Pollack: SoÂ whatâ€™s next? Now that CLASS has failed. Is there anything thatâ€™s going to come in its place?
Gleckman: Â The fiscal cliff law does create a new commission which is tasked to come up with a solution to the financing problem, and also to address delivery and workforce issues….
We havenâ€™t really done a good review of long-term care policies since the Pepper commission in 1990. Itâ€™s absolutely time that we do it again.
But this commission will be hamstrung by a very short time frame. Its members must be appointed within 30 days. The commission has to make its recommendations within six months after that. I honestly donâ€™t think itâ€™s possible to perform a serious review and deliver a set of serious proposals in six months.
Itâ€™s also concerning that this commission is not connected to any federal agency. Normally, you would think that something like this would have some connection with the Department of Health and Human Services, but itâ€™s not. Itâ€™s floating around out there with no bureaucratic home.
There is also no requirement that Congress actually vote on any of these recommendations. The Commission is required to submit its recommendations in six months but Congress could ignore them. I donâ€™t know where that leaves us.
Pollack: If anything, I think youâ€™re wildly overoptimistic. It just seems like itâ€™s going to head straight to the writeâ€‘only memory, as we used to say in engineering school.
Gleckman: Â I think thatâ€™s right. There are two reasons why Congress creates commissions. The first is that there is an intractable problem they want to get all the parties to sit down and work out. That was the case a few years ago, when there was a broad consensus that we needed to close military bases. The normal regular order of Congress wasnâ€™t going to do it. So Congress turned it over to a commission. Everybody had agreed in advance what they wanted to do. Then there is the more common commission, which essentially is a way to make it look like youâ€™re doing something when youâ€™re really not. I fear that is what this one is.
See the full interview here.
I won’t vote for Senator Mark Kirk. But his simple words today command respect.
I published something today about the sad demise of the the Community Living Assistance Services and Supports Act (CLASS). CLASS was a component of health reform designed to help people who live with a variety of disabilities live more independently and (whenever possible) to stay in their homes. Itâ€™s a brilliant article. I hope that you read it.
Then, by chance I encountered a Sun-Times interview today with Illinoisâ€™ Republican Senator Mark Kirk. About a year ago, Kirk suffered a stroke. Heâ€™s been slowly and courageously recuperating ever since. He suffers from paralysis on the left side of his body. He has difficulties with the left side of his face.
In describing his ordeal and his recovery, Kirk noted the following:
â€œI will look much more carefully at the Illinois Medicaid program to see how my fellow citizens are being cared for who have no income and if they suffer from a stroke,â€ Kirk said.
He said in general a person on Medicaid would be allowed 11 rehab visits in Illinois. â€œHad I been limited to that I would have had no chance to recover like I did. So unlike before suffering the stroke, Iâ€™m much more focused on Medicaid and what my fellow citizens face.â€ [italics added.]
The simple truth in these commentsÂ commands respect. Kirk required aggressive rehabilitation services at one of America’sÂ finest facilities for patients recovering from stroke. Such a profound physical ordeal–and oneâ€™s accompanying sense of profound privilege in securing moreÂ help than so many other people routinelyÂ receiveâ€”this changes a person.
Politicians and policy analysts often speak in the abstract aboutÂ difficult tradeoffs and the need to trim waste in programs such as Medicaid. Iâ€™ve expressed contempt for conservatives who conduct such conversations at such very great personal distance from the people intimately affected by service cuts in essential programs. Of course, we liberals conduct many of these same conversations at the same psychological distance, too.
Caring for my brother-in-law Vincent has certainly changed my perspective. Whatever the issues are, they aren’tÂ about some group of faceless other people anymore.
Vincent,Â intellectually disabled since birth,Â has not physically suffered in the way Senator Kirk has. He doesÂ face other challenges.Â Vincent is, officially, a pauper. He swipesÂ his food assistance and his Social Security over to the group home that provides for his daily needs.
He is entitled to keep $50 per month for personal discretionary spending. Thatâ€™s not a lot. It’s expectedÂ to cover every shirt, McDonaldâ€™s hamburger, or ESPN magazine. That $50 is even less now. Vincent requires podiatry care for a complicated toe problem that has already required multiple hospitalizations. Illinois Medicaid no longer pays the $17/month he requires for this care. Illinois has dropped adult dental coverageâ€”another punishing blow for too many people.
Vincent has us to help him address these difficulties. Many of his friends and housemates arenâ€™t so lucky. Theyâ€™ve outlived their primary caregivers, or theyâ€™ve outlived these relationships. For some, their closest contact with a living relative is a birthday card and maybe a Christmas dinner.
I wish Senator Kirk all the best in his return to work this week. I should mention that I didnâ€™t vote for him. Indeed, I walked door-to-door for his Democratic opponent. I will do so again.
Yet as Washington gets down to brass tacks in negotiating budgets and social policy, Iâ€™mÂ glad that Senator Kirk will be there. I hopeÂ his personal experiences will help him temper his partyâ€™s tough positions on Medicaid and so many other things. He has special reason to know better.
Kevin Drum notes that Republicans insist on something called “entitlement reform,” but have no actual ideas about what this reform might meanÂ (aside from getting rid of Medicare).Â So now they are insisting that President Obama make the first offer, which is a laughable position.Â The also insist on “putting Obamacare on the table”, which the White House immediately rejected.
But maybe it shouldn’t.Â If we’re talking about reducing entitlement payments, wouldn’t it be great if we could find something that could save, say, $500 billion over ten years, but not reduce access to coverage and actually make the health careÂ system more efficient?
Oh wait: we do!Â Remember the public option?Â That’s what it would do, according to the Lewin Group and the Urban Institute.Â Â Both studies estimated a public option at saving the federal budget $50 billion a year.Â And if anything, those estimates are conservative, because they do not assume that Medicare providers would be mandated to accept public option patients (as they should be), and they also assume large “cost shifts,” i.e. increases in private insurance costs, which have no empirical basis.Â So I say put Obamacare on the table and put in a strong public option.
What’s that you say? That such an action would reform entitlements and save money, but that the Republicans would never go for it?Â Gosh, it’s almost as if the GOPÂ doesn’t really care about saving money and really only wants to cut people off of health insurance.Â I can’t imagine why anyone would think that.
It is a shame that the VP debate did not delve into the proposal of Gov. Romney and Rep. Ryan to block grant Medicaid in a way designed to greatly reduce federal spending on the program; this is where the most profound disagreements on health policy can be found in this election. Aaron Carroll and Austin Frakt have a nice graph depicting both the stark difference in proposed spending on Medicaid between the President and Gov. Romney, as well as the stark similarity in their planned Medicare spending over the next 25 years:
Pardon the most boring title in the history of RBC.
Pardon the most boring title in the history of RBC.
Until late August, Republicansâ€™ political and policy approach to entitlements rested on four pillars:
- Deep cuts to Medicaid, accompanied by a block grant structure which shifts costs and risks away from the federal government and onto individuals, states, and local governments.
- Repealing health reform, and thus forestalling both the Medicaid expansion and the range of protections and subsidies embodied in health insurance exchanges.
- Transforming Medicare from a defined-benefit to a voucher program in which traditional Medicare competes with private plans.
- Congratulating themselves for making hard choices on entitlements while simultaneously appealing to the over-55 Republican base by hammering the Democrats over the $716 billion in Medicare payment cuts included in the Affordable Care Act.
The first two pillars remain in place. For all the criticisms of Governor Romney for his vagueness, his approach to Medicaid and health reform are all too clear. Repealing health reform will result in roughly 30 million Americans going uncovered who would otherwise be insured. â€œRepeal and replace,â€ along with the block- granting and cutting of Medicaid will reduce federal support for Medicaid by roughly one-third a decade from now, maybe more….
The third pillar is there, too, but things are more complicated. Republicansâ€™ voucherÂ approach over the past several yearsâ€”and its policy justificationâ€”were stated with admirable clarity in this yearâ€™s Republican platform: Continue reading “Contra David Brooks, there is no â€œmarket systemâ€ alternative to the political system in running Medicare”
My gchat with Austin Frakt.
In time for tonight’s debate, the Incidental Economist‘s Austin Frakt and I had a nice gchat conversation about Medicare and Medicaid issues likely to arise in tonight’s debate.Â Check it out here, including the very nice HIO artwork shown below. The picture below, used in one of my previous pieces, communicates in one picture so much of what I found missingÂ atÂ this year’sÂ GOP convention.
(During the debate, I will be live-chatting with staff atÂ The Nation here. For those who need more, here are my comments on Morning Edition and All Things Considered on related issues. Oh yeah.Â my Medicaid political spotÂ has attracted 10,321 views. That seemed OK until the #1 recommended related video was some cat thing that has attracted 1.75 million….)
Here’s Austin’s concluding thought in our gchat.
Austin: Iâ€™d end with this: This election offers the starkest choice on health care weâ€™ve ever had. The choice is more clear than it was in 2008, because ACA is now law. Therefore, we know almost exactly what will happen if Obama wins. In 2008, we had only his plan to go on. The law is far more detailed. Similarly, since Romney has pledged repeal, we know very well what heâ€™d do. Heâ€™s been less than clear on some other reforms, but we can see the thrust quite well, and it is the opposite direction â€“ in terms of coverage expansion â€“ than Obama.
So, we have a clear choice on election day, donâ€™t we?
I made this unironic two-minute campaign spot: “We are all vulnerable.” I’m grateful to Frey Hoffman, who shot the actual video. I am responsible for the script and everything else. I hope you like it.
Stuart Altman, Jon Gruber, and John McDonough compare what will happen under a fully-implemented ObamaCare, Massachusetts’ RomneyCare, and what they impishly call “RomneyCandidateCare…”
Families USA released a report today authored by three health policy luminaries: Stuart Altman, Jon Gruber, and John McDonough. They compare what will happen under a fully-implemented ObamaCare, RomneyCare (a fully-implemented national version of the Massachusetts plan enacted under Governor Romney), and what would happen if Romneyâ€™s current proposals were enacted instead. The authors impishly call the latter possibility RomneyCandidateCare.
No one should be surprised that RomneyCandidateCare would be a huge step backwards for sick, low-income, and the uninsured. (Iâ€™ve written quite a bit about that here, and at www.healthinsurance.org/blog/.)
Throughout the primaries, Romney and every other GOP candidate thundered against ObamaCare. Vice presidential candidate Paul Ryan has called for repeal, along with $800 billion in additional Medicaid cuts over the next decade.
The 2012 Republican platform states: “Congressional Republicans are committed to its repeal; and a Republican President, on the first day in office, will use his legitimate waiver authority under that law to halt its progress and then will sign its repeal.â€
Republicans also propose deep Medicaid cuts. Rather than cover 30 million people as ObamaCare would, the Republican platform would actually increase the number of uninsured. The same GOP-base legislators who produced the above platform would be the ones to write the fine print of Republican health reform legislation. We should take this emphatic language very seriously.
Things could have gone differently… Continue reading “ObamaCare=RomneyCare (for nonseniors). RomneyCandidateCare=…”