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January 24, 2010

If we want to expand Medicaid, we've got to enhance it

I've heard several progressives suggest that Democrats abandon comprehensive health care reform and just expand Medicaid to cover everyone who can't afford insurance. Expanding Medicaid could provide coverage for 35-45 million Americans and ultimately save billions of dollars.

Now that the Democrats' filibuster-proof majority is toast, reformers are brainstorming alternative routes to reform. According to one school of thought, the House should just pass the Senate bill, or a modified version thereof. Another camp maintains that the bill should be broken down into smaller, less controversial chunks which the Republicans wouldn't dare filibuster. Be skeptical of any political strategy predicated on the assumption that something is so universally beloved or obviously beneficial that the GOP wouldn't dare obstruct it.

Maybe it would be easier to pass the Medicaid expansion alone than it would be to get the House to pass any version of the Senate bill. Both the House and the Senate have already passed bills that would expand Medicaid. A Medicaid expansion might placate the two main pockets of opposition to the Senate bill in the House: the anti-abortion contingent and the public option purists.

Medicaid-only might shut up Bart Stupak and his anti-choice cronies, assuming they aren't just using abortion as a poison pill to kill health reform. The Hyde Amendment already applies to the federal side of Medicaid, so the anti-choicers can't truthfully say they're being forced to vote for an expansion of abortion coverage. Though, again, be skeptical of a political strategy that assumes anti-choicers won't lie about easily checkable points of fact or law. After all, they claimed that the Capps compromise was federal funding for abortions.

Finally, Medicaid-only would be a win for all the House progressives swore they'd never vote for a bill without a public option. Medicaid is the ultimate public option.

So, let's assume it's easier to pass Medicaid-only than the full Senate bill. Would expanding Medicaid ultimately provide better insurance for more people?

Ellen-Marie Whelan, a nurse practitioner and an analyst at the CAP Action Fund says it's not that simple. Practitioners who accept Medicaid are already in short supply. Adding tens of millions of people to the Medicaid rolls without beefing up the program will push health care further out of reach for millions of Americans.

In her latest Wonk Room post, Whelan outlines a plan to strengthen Medicaid and the public health system in order to accommodate millions more beneficiaries. 

So, "Medicaid-only" really means "Medicaid expansion, plus higher reimbursement rates, plus training more primary care providers and public health workers." That's still a dramatically streamlined proposal compared to the Senate bill. Nothing in Whelan's proposal would alienate the anti-choicers or the public option proponents.

The question remains whether it would really be easier to pass Medicaid expansion vs. a modified Senate bill. The Blue Dogs wouldn't like it and the unions would be upset that the excise tax stayed in the picture.


Howard Dean advocates expanding both Medicaid and Medicare:

"You could simply expand the Medicare program that everybody knows to people who are over 55 instead of 65. The House and the Senate passed very good expansions in Medicaid which helps young people, for example, and hard working people with no insurance. Those are the kinds of things that you can do. And we can run those through reconciliation. The chairman of the Budget Committee said he'd be willing to look at things in the budget bill."

I agree with you that Medicaid reimbursment rates should be raised.

Expanding Medicaid without also getting the regulatory reform aspects of reform would be a political disaster. Republicans would spin it as a giveaway to Those People, and Democrats wouldn't have anything tangiable to show people who wouldn't be covered by the expansion. And from a policy stand point, you'd leave the shoddy practices of the insurance industry in place.

This has two major problems.

1. It's not universal coverage - not even close. The minimum required for universal coverage within the current system is community rating, a mandate, and subsidies, i.e. the Senate bill.

2. Medicaid is supremely expensive - it costs more than $10,000 per person it covers. A bill using Medicaid/Medicare as a base has to include significant cost control to avoid busting the budget, but then it triggers the usual "Don't you touch my Medicare" attacks.

It's not even close to universal coverage. But as the old saying goes, the Blues is not about limitless choice.

I support universal coverage for all US citizens and for all legally here, not just for those who can't afford it

But how to handle those who are illegally in the US? Should there be any difference in how coverage is afforded to them, by insurance plans or by how hospitals are obligated to provide treatment for them?

This is a tough issue that has been finessed by many who don't want to deal with the issue of illegal immigration.

Whaddaya say?

The Phantom -

"Although the House-passed bill allows illegal immigrants to pay for insurance through the exchange with their own money, the Senate bill says they have no access to the exchange at all."

Phantom: the lowest-cost forms of universal health care, i.e. single-payer with private add-on plans, are based on having as little administration as possible checking who you are before you get care. This means that illegal immigrants would get subsidized health care, but denying them health care would cost more money in administrative spending than it would save.

The Senate bill version has a similar issue - denying illegal immigrants access to subsidized insurance would mean they'd get treated without insurance, forcing hospitals to pass the costs to the insured population. It would also require removing the mandate for illegal immigrants, which means that among illegal immigrants who could afford insurance, the healthy ones would choose not to get it, creating adverse selection and forcing premiums up for everyone else.

Stop feeding bullshit.
Democrats never had a filibuster-proof majority. Not with Lieberman and Nelson, they didn't.

Younger, relatively healthier clients would bring down the cost per patient.

Last I heard, Medicaid requires one to deplete all assets. Then, if something major happens there is a lien on your house, if you own.

Bad as it may be, the Senate bill would provide some bankruptcy protection.

I think the Senate bill should be passed, making it, and not the status quo, the starting point for further reform.

This is an election year. There has been way too much dithering on this issue. I don't think there's time to start from scratch. I think starting from scratch equals a repeat of 1994

One thing about Medicaid is generally, the "able-bodied" can't get it. If you're healthy and able to work, generally you can't get welfare, and the associated Medicaid.

In the case of Medicare, the universe is 65 and older, and people who have disabilities, both universes that consume medical services at higher rates than the population at large.

I think the groups have a much higher percentage of ill or susceptible people than the population as a norm. So, presumably, among the 35-45 million uninsured Americans, there is a higher percentage of healthy people, hence the per-person costs should be lower.

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