President-Elect Trump’s “Better Way”: Expanding Managed Medicaid or Medicare for ALL or….?

Posted on | November 17, 2016 | Comments Off on President-Elect Trump’s “Better Way”: Expanding Managed Medicaid or Medicare for ALL or….?

Image: KFF

Mike Magee

This is the week for speculation, especially when it comes to insuring the health of U.S. citizens. With President Obama’s departure, the Affordable Care Act is clearly at risk. The Republicans, with Paul Ryan at the helm, have attempted to challenge the bill over 50 times since its’ inception, the last being on January 16, 2016, when they threw in dissolution of Planned Parenthood funding for good measure.

Perhaps it’s best then to start with the facts. 91% of Americans now have some form of health insurance. 49% receive coverage through their employer. 20% rely on Medicaid. (That’s 77 million, including 12 million new ACA Medicaid beneficiaries, with 80% of all beneficiaries in some sort of capitated managed Medicaid.) 14% are Medicare enrollees. 7% maintain other private plans. 2% have CHIP, VA coverage, or other federal insurance. And 9% remain uncovered; that’s 28.5 million out of 318,896,000 citizens more or less.

The Affordable Care Act, for all the criticism, has managed to cover an additional 20 million during its opening years. That alone is a pretty remarkable feat considering that the many Republican led states sat on their hands, and the Republican Congress challenged the bill day in and day out for years. But that was then and this is now.

The first issue that is likely to be cued up is Medicaid for two reasons – one ideological, the other financial. On the ideological side, Republicans favor safety net solutions to be state run, free market oriented, and with strings attached like mandatory work and participant co-pays. On the financial side, Republicans favor small government, low taxes, and short term commitments.

Considering the above, it’s pretty remarkable that President Obama identified a sweet spot when it came to incentives to expand state sign-up’s for Medicaid as part of the ACA. True, 19 red states did boycott the program. But some Republican governors were all in, and their names are familiar by now.

Mike Pence’s program in Indiana demanded “personal responsibility” and insisted that beneficiaries fund their own health savings accounts. According to Medicaid.gov, “As of August 2016, Indiana has enrolled 1,481,869 individuals in Medicaid and CHIP — a net increase of 32.23%”

Chris Christie, who’s state is in financial ruins, was pleased to add some 500,000 Medicaid beneficiaries and cheered the fact that they now had “more and better health care”. According to Medicaid.gov, “As of August 2016, New Jersey has enrolled 1,757,341 individuals in Medicaid and CHIP — a net increase of 36.88% since the first Marketplace Open Enrollment Period and related Medicaid program changes in October 2013.”

The 12 million added to the Medicaid rolls through the ACA were funded through a sweet deal. 100% of the state costs would be covered for three years and then 90% after that. (Under the standard Medicaid arrangement, federal contributions vary by state with 1/2 to 2/3 of the bill currently paid by the federal government.) And even in the red states that thumbed their nose to expansion, they were pleased to have help funding an average 2/3 of their nursing home residents, and in some cases 1/2 of the maternal-fetal care of economically disadvantaged women.

Still, studies show that the non-participating states, most with outsize populations of economically disadvantaged citizens, passed up a staggering $423 billion in federal dollars over the first decade of the program to spite President Obama and his signature legislation. When you look at a poor state like Mississippi, you get a true feel for the cost of their willfulness. Over the first decade of the program, they will have declined an amount equal to just under $5000 for every man, woman, and child in the state.

With both money and coverage on the line, it will be interesting to watch the Republicans next move. They’ve already signaled their financial intents with Paul Ryan’s “Better Way” proposition. But then again, there’s the small issue of President-elect Donald Trump. He’s a free thinker and likes getting a bang for his buck.

He also detests bad deals, and if there was ever a poster child for a horrid one, it would have to be America’s jury-rigged, partly employer based, US health care system overflowing with inefficiencies, high cost, inequity, double-dipping, over-prescribing, spotty distribution, and variable quality.

Our President-Elect has already flirted in the past with a universal health care system. Maybe he has a “better way” of his own. If so, he’d likely find support similar to that voiced by Michael Sparer in this week’s NEJM who wrote, “Another idea that has emerged is to create a ‘public option’ — a new government plan that would either compete nationally or, more likely, provide a public-insurance safety net in markets lacking adequate private competition.” You never know. Maybe President-Elect Trump will go for broke. If so, two likely candidates for further expansion would be Managed Medicaid and Medicare for all.