Here is the C-span link to the Supreme Court opinion on the ACA.
Who would have thought that logic (i.e., a mandate that is enforced as a tax is a tax! and Medicaid is a voluntary program, that States can opt out of in pieces) would prevail?
Is this another switch in time that saved nine? Or the opposite? Only time will tell. My relief tells me exactly where my own opinions lie.
Showing posts with label Medicaid. Show all posts
Showing posts with label Medicaid. Show all posts
Jun 28, 2012
Jun 24, 2012
What's the best outcome of SCOTUS on Obamacare?
Here we are, on the possible eve of the supreme court's decision on the constitutionality of the Affordable Care Act (ACA). I've been grappling with what I want to see as the outcome, from the standpoint of what's good for the health care system, what's good for Obama's reelection, for the Democrats in Congress, and finally, for the crowd of people who deeply believe that a single-payer health care system (a la Medicare) is best for the entire country. To clarify, when I think about what's good for the health care system, I have in mind the ultimate effects on cost, quality and equality of access...those three competing objectives of public policies governing the delivery of health care.
What's good for Obama's re-election? I believe the best thing for Obama politically speaking is to have the whole bill nullified (except for the Medicare provisions, which nobody is talking about anyway). That would wipe out the state-level exchanges, the insurance mandate (of course), and all the Medicaid provisions that expand access to Medicaid to all individuals and families with incomes less than 133% of the Federal poverty line (about $14K for individuals; and $31K for a family of four). I can't imagine how striking down the insurance mandate could leave in tact the ban on insurers discriminating on the basis of pre-existing conditions, or even the requirement to cover the under-26 crowd (even though some major insurers say they will keep that one.)
I think it would be good for voters to go back to square zero on health care. It would take the fire out of the conservatives' righteously(?) indignant bellies over the mandate, while leaving the rest of the country to mull the alternatives.
What's good for the Democrats in Congress? Re-election wise, see above. Ideologically wise? What ideology? Dollars (theirs) is what matters to them.
What's good for the Single-payer ideologues? This is a no-brainer. The mandate goes, the Medicaid provisions stay. Most Americans do not realize that the Medicaid provisions, in addition to expanding eligibility, require Medicaid to pay for physician services at Medicare rates.. We hear a lot about how Medicare fees are low compared with private rates, but Medicaid fees are 30% lower than that! And, to top it all off, the Federal government will pick up the entire tab for the health care costs of the new eligibles. (Yes, yes, that's for 2 years, after which the Federal % drops to 90% and the Medicaid fee schedule rule drops, but who believes that the doctors won't have the clout to extend the fee schedule, just as they have managed to keep fees from plunging under Medicare's law by one-year extensions?)
Bottom line: an extension of the Medicare-like single-payer system to a greater part of the population, and a gradual acclimation of the public to the idea that universal coverage can only come from a single-payer system.
What's good for the Health Care System? At this point, I am rooting for a complete nullification, though I am aware it's a long-shot. That's because I don't believe in a single-payer system. So, what I mean is that if the mandate is going to be shot down, then I hope they shoot down Medicaid, too. That way, in having to start from scratch, perhaps Congress will put all the people into exchanges, which will treat the lower-income folks with the same respect they treat others. And, instead of "exchanges," it should be "exchange." I believe in a regulated market place (much like the Federal Employees Health care system) that offers competing plans meeting minimum coverage requirements. The exchanges sounded like a good idea, but they are implemented at the state level, which doesn't allow much ability to pool risks, especially in smaller states. (The state-level exchanges came from the Senate and its nefarious (Demorcatic) leadership, while the (Democratic) House bill had a national exchange system that would have guaranteed a large pool of enrollees.)
At this point, it would be worthwhile to go back to ground zero and let the nefarious Republican leadership deal with the consequences of its political intransigence and the public with another failure of our country to make access to health insurance (and therefore decent access to health care) a right.
What do you think?
What's good for Obama's re-election? I believe the best thing for Obama politically speaking is to have the whole bill nullified (except for the Medicare provisions, which nobody is talking about anyway). That would wipe out the state-level exchanges, the insurance mandate (of course), and all the Medicaid provisions that expand access to Medicaid to all individuals and families with incomes less than 133% of the Federal poverty line (about $14K for individuals; and $31K for a family of four). I can't imagine how striking down the insurance mandate could leave in tact the ban on insurers discriminating on the basis of pre-existing conditions, or even the requirement to cover the under-26 crowd (even though some major insurers say they will keep that one.)
I think it would be good for voters to go back to square zero on health care. It would take the fire out of the conservatives' righteously(?) indignant bellies over the mandate, while leaving the rest of the country to mull the alternatives.
What's good for the Democrats in Congress? Re-election wise, see above. Ideologically wise? What ideology? Dollars (theirs) is what matters to them.
What's good for the Single-payer ideologues? This is a no-brainer. The mandate goes, the Medicaid provisions stay. Most Americans do not realize that the Medicaid provisions, in addition to expanding eligibility, require Medicaid to pay for physician services at Medicare rates.. We hear a lot about how Medicare fees are low compared with private rates, but Medicaid fees are 30% lower than that! And, to top it all off, the Federal government will pick up the entire tab for the health care costs of the new eligibles. (Yes, yes, that's for 2 years, after which the Federal % drops to 90% and the Medicaid fee schedule rule drops, but who believes that the doctors won't have the clout to extend the fee schedule, just as they have managed to keep fees from plunging under Medicare's law by one-year extensions?)
Bottom line: an extension of the Medicare-like single-payer system to a greater part of the population, and a gradual acclimation of the public to the idea that universal coverage can only come from a single-payer system.
What's good for the Health Care System? At this point, I am rooting for a complete nullification, though I am aware it's a long-shot. That's because I don't believe in a single-payer system. So, what I mean is that if the mandate is going to be shot down, then I hope they shoot down Medicaid, too. That way, in having to start from scratch, perhaps Congress will put all the people into exchanges, which will treat the lower-income folks with the same respect they treat others. And, instead of "exchanges," it should be "exchange." I believe in a regulated market place (much like the Federal Employees Health care system) that offers competing plans meeting minimum coverage requirements. The exchanges sounded like a good idea, but they are implemented at the state level, which doesn't allow much ability to pool risks, especially in smaller states. (The state-level exchanges came from the Senate and its nefarious (Demorcatic) leadership, while the (Democratic) House bill had a national exchange system that would have guaranteed a large pool of enrollees.)
At this point, it would be worthwhile to go back to ground zero and let the nefarious Republican leadership deal with the consequences of its political intransigence and the public with another failure of our country to make access to health insurance (and therefore decent access to health care) a right.
What do you think?
Mar 1, 2012
A Great Guide to the Supreme Court's Upcoming Review of the Health Reform Law
The Supreme Court seems to be taking this seriously, admitting (???) that they need help in understanding the issues by scheduling 6 hours of argument (compared with usual 1 hour). A great article in the New England Journal of Medicine, available without a subscription, lays out the issues and the timeline. It's written for doctors, so it's actually readable for us all, since so many docs don't seem to understand anything about insurance markets and cost control (my editorial comment, of course). Update as of Mar 15, another article in NEJM. Clearly, the profession cares about this
Mar 26, 2010
Health Care Reform Timetable
Here's a good summary, from the Kaiser Family Foundation, of what will happen when, as health care reform ramps up over the next few years. See Health Care Reform Timetable.
Mar 20, 2010
Hypocritical congress manipulates CBO esimtates.
An old theory states that regulated industries ultimately "capture" the relgulators and are able to mold the rules to their own advantage. Too bad the theory always seems to work in practice. Now we're seeing it in the manipulation of the CBO scoring process by the "regulated" Congress. Keith Hennessey posted an example of how the House has crafted a Medicaid provision in the reconciliation bill that requires states to pay doctors the same as Medicare pays them, and HAVE THE FEDERAL GOVERNMENT PICK UP THE TAB, without being charged with a $52 billion ten-year cost that CBO estimated for that provision in the original House Bill. The reconciliation bill limits the years in which those increased fees would apply to only two --- 2013 and 2014 -- which brings the cost down to only $8 billion over ten years.
Of course, everyone knows that once those increases go into effect, Congress will never let the fees go back to the old rules. Look what's happened to the physician fee reductions passed in 1997 for Medicare. Each year Congress passes an over-ride, and the reductions are "delayed" for another year. That's what will happen here. So, the health reform bill will effectively federalize Medicaid and add it to the Medicare fee-for-service system (the system that "works so well"). State leaders will love it. Less payout for Medicaid. Doctors will like it, and more of them will participate in Medicaid, which is good for poor people, and by extension the rest of us. Let's face it, though...our deficit hole will just grow and grow and grow.
CBO has no choice but to score the bill this way. It has to assume the law will operate as it says in the bill it's scoring at the time, not as it will play out in reality. This manipulation of legislative language by Congress has improved over time, so at this point the "CBO score" is largely a political football, with the majority using it to hide major new cost-raising changes.
This is just one of dozens of little "surprises" lurking in the bill -- which I admit I still have not read in full and probably never will. What I'm learning is from newspapers and internet. Keith Hennessey's blog is a jewel . I may not agree with him on priorities, but he's an excellent analyst of policy and politics. And he's not lazy. He actually read the reconcilation bill.
Of course, everyone knows that once those increases go into effect, Congress will never let the fees go back to the old rules. Look what's happened to the physician fee reductions passed in 1997 for Medicare. Each year Congress passes an over-ride, and the reductions are "delayed" for another year. That's what will happen here. So, the health reform bill will effectively federalize Medicaid and add it to the Medicare fee-for-service system (the system that "works so well"). State leaders will love it. Less payout for Medicaid. Doctors will like it, and more of them will participate in Medicaid, which is good for poor people, and by extension the rest of us. Let's face it, though...our deficit hole will just grow and grow and grow.
CBO has no choice but to score the bill this way. It has to assume the law will operate as it says in the bill it's scoring at the time, not as it will play out in reality. This manipulation of legislative language by Congress has improved over time, so at this point the "CBO score" is largely a political football, with the majority using it to hide major new cost-raising changes.
This is just one of dozens of little "surprises" lurking in the bill -- which I admit I still have not read in full and probably never will. What I'm learning is from newspapers and internet. Keith Hennessey's blog is a jewel . I may not agree with him on priorities, but he's an excellent analyst of policy and politics. And he's not lazy. He actually read the reconcilation bill.
Oct 13, 2009
Medicare, Medicaid, and Mayo Clinic
Today's Washington Post has an article about Mayo Clinic's decisions to opt out of Medicare for primary care in its Scottsdale Arizona campus and to refuse to accept Medicaid patients from certain mid-western states. Here's a link to an Oct. 9 news article in the Arizona Republic covering the Medicare decision .
Doctors all over the country refuse to accept Medicaid because of states' tendencies to pay even less for physician services than does Medicare. So, Mayo's opting out of some states is no big thing, in my view. The miracle is that they do participate in the Medicaid programs of MN, WI, ND and SD.
But, the decision of Mayo Scottsdale to refuse Medicare for primary care needs more consideration. Sounds heartless on its face, but my reading is different.
Here's what Mayo-Scottsdale is probably doing to stay within the confines of the law. It must be designating certain of its doctors (those manning one of its family practice facilities) as "opt-out" physicians. That Medicare jargon means that those doctors will not accept Medicare payment for any of their patients, and Mayo will not submit a bill on behalf of the patient for any of the services rendered by those doctors to Medicare patients. The patient is on the hook for the entire charge, and Medicare won't pay a penny for the services provided by an opt-out physician. Hear me? The patient cannot get a penny from Medicare when treated by an opt-out physician. Mayo is charging the Medicare patient who wishes to have a Mayo primary care physician an annual access fee of $250, plus fees for visits that are higher than the Medicare fee schedule allows.
Once the patient needs to see a specialist of any kind (say a radiologist, an endocrinologist, yada yada), or needs lab work, or special procedures, however, Mayo will bill Medicare on behalf of the patient. And, in that case, by law, Mayo must get no more than about 115% of the fee allowed by Medicare. So, the patient is completely on the hook at Mayo only for the services of the primary care internist.
Now, the unpleasant reality is that most Medicare patients who would pay, say, $1000 each year in excess fees are unlikely to be poor. So, the criticism of Mayo as catering to the elite in its primary care is somewhat valid. (Why do you think they located a new campus in Scottsdale in the first place?) But, --and here I am an expert as a sometime member of the Mayo (Rochester) staff and an occasional patient -- what the patient gets for that extra money is the kind of attention that most of us see only in Norman Rockwell paintings. First off, the Mayo community medicine doctor lets you talk and talk. You NEVER feel rushed. This is really true! He or she takes a thorough history. The visit almost always takes over a half-hour. (Time your next routine visit to your internist to compare.) You feel as if the doctor hears you. It's wonderful. Need a referral to a specialist? You get it, and you get it fast. Need lab work? It's done there, and the results come back quick. You're not left waiting for a month as you schedule that consult across town.
Does this make Mayo infallible? I haven't found it so. Those doctors have missed things in my case. Still, I never feel angry because I chalk it up to the inevitable imperfection of doctors in the face of mind-numbing variability and complexity of human disease. I've never chalked it up to the doctor not caring. Out here in the real world, though, I often do chalk it up to that.
Now, it's no secret that Medicare underpays for primary care services relative to specialist care. See Kaiser Family Foundation's background piece on the shortage of primary care docs. So, rather than start rushing patients through the system to meet its costs, Mayo has taken a stand against Medicare's crazy fee-for-service system. Lower income Medicare patients, or those who take umbrage, will have to see other docs for their primary care; they can still be referred by those doctors for specialty care at Mayo.
This is a signal to the Medicare fee-for-service system. You just don't work!
Doctors all over the country refuse to accept Medicaid because of states' tendencies to pay even less for physician services than does Medicare. So, Mayo's opting out of some states is no big thing, in my view. The miracle is that they do participate in the Medicaid programs of MN, WI, ND and SD.
But, the decision of Mayo Scottsdale to refuse Medicare for primary care needs more consideration. Sounds heartless on its face, but my reading is different.
Here's what Mayo-Scottsdale is probably doing to stay within the confines of the law. It must be designating certain of its doctors (those manning one of its family practice facilities) as "opt-out" physicians. That Medicare jargon means that those doctors will not accept Medicare payment for any of their patients, and Mayo will not submit a bill on behalf of the patient for any of the services rendered by those doctors to Medicare patients. The patient is on the hook for the entire charge, and Medicare won't pay a penny for the services provided by an opt-out physician. Hear me? The patient cannot get a penny from Medicare when treated by an opt-out physician. Mayo is charging the Medicare patient who wishes to have a Mayo primary care physician an annual access fee of $250, plus fees for visits that are higher than the Medicare fee schedule allows.
Once the patient needs to see a specialist of any kind (say a radiologist, an endocrinologist, yada yada), or needs lab work, or special procedures, however, Mayo will bill Medicare on behalf of the patient. And, in that case, by law, Mayo must get no more than about 115% of the fee allowed by Medicare. So, the patient is completely on the hook at Mayo only for the services of the primary care internist.
Now, the unpleasant reality is that most Medicare patients who would pay, say, $1000 each year in excess fees are unlikely to be poor. So, the criticism of Mayo as catering to the elite in its primary care is somewhat valid. (Why do you think they located a new campus in Scottsdale in the first place?) But, --and here I am an expert as a sometime member of the Mayo (Rochester) staff and an occasional patient -- what the patient gets for that extra money is the kind of attention that most of us see only in Norman Rockwell paintings. First off, the Mayo community medicine doctor lets you talk and talk. You NEVER feel rushed. This is really true! He or she takes a thorough history. The visit almost always takes over a half-hour. (Time your next routine visit to your internist to compare.) You feel as if the doctor hears you. It's wonderful. Need a referral to a specialist? You get it, and you get it fast. Need lab work? It's done there, and the results come back quick. You're not left waiting for a month as you schedule that consult across town.
Does this make Mayo infallible? I haven't found it so. Those doctors have missed things in my case. Still, I never feel angry because I chalk it up to the inevitable imperfection of doctors in the face of mind-numbing variability and complexity of human disease. I've never chalked it up to the doctor not caring. Out here in the real world, though, I often do chalk it up to that.
Now, it's no secret that Medicare underpays for primary care services relative to specialist care. See Kaiser Family Foundation's background piece on the shortage of primary care docs. So, rather than start rushing patients through the system to meet its costs, Mayo has taken a stand against Medicare's crazy fee-for-service system. Lower income Medicare patients, or those who take umbrage, will have to see other docs for their primary care; they can still be referred by those doctors for specialty care at Mayo.
This is a signal to the Medicare fee-for-service system. You just don't work!
Sep 15, 2009
The Senate Finance Committee's Health Reform Plan
This is the "Baucus Committee", which is generally more conservative than the Senate HELP Committee (Kennedy, Dodd & Harkin). The SFC's bill hasn't been drafted fully, but last week Sen. Baucus released an 18-page summary of its provisions so far. I relented from my new "kill-no-trees...create-no-paper-waste" policy and actually printed a copy and then actually read the thing.
Here are some things to worry about in this bill (and why):
Here are some things to worry about in this bill (and why):
- Insurance market reforms - (p2-3) - Although plans would have to refrain from discriminating against pre-existing conditions & must eliminate lifetime limits on coverage, they could vary premiums by age group, up to a ratio of 5-to-1! That's pretty substantial for the 50+ crowd who are likely to need the most care. It's basically saying that each age-group of uninsured will subsidize itself. No transfer from the young to the old. It would not provide real relief on premiums for the older laid-off crowd that can't change careers fast. Oh, and by the way, plans could offer a super-cheap policy for the "young invincibles" who wanted only catastrophic coverage, thereby siphoning off the lowest risk segment of the population from the general market. End result? VERY HIGH PREMIUMS for older uninsured people. Makes the idea of "affordability" laughable for anyone who isn't young and healthy or near-poor (see below).
- Benefit options- (p3) - Oops! First I got this wrong. I thought that the summary was saying that Plans could keep 35% of premium collections for their own expenses & profits. What they really meant was that each plan's benefit would have to limit patients' out-of-pocket expenses to 35% of total costs (on average across enrollees). That's much better. So, I'm not worried about the plan options they're talking about.
- Health Insurance Exchanges - these would be set up and run by the states, instead of a Federal bureaucracy. Excuse me, but I'm from New Jersey. (Enough said?) In all my years working in Washington near or in the Federal workforce I've never seen the incompetence, waste and corruption that I've followed in my home state. (Well, maybe in my first years as an intern in a dying federal agency.) It's a bad idea in this case not to have the regional markets organized by a central commission. There, instead of 50 state bureaucracies reviewing insurance offerings for their fine print, you'd have just one. Regions would be distinct, but the expertise to regulate the markets would be centralized (like Medicare).
- Medicaid - (p. 7-9) This section is unclear, but it appears that people between 100% and 133% of poverty will be able to choose between Medicaid and the Health Insurance Exchange. That's good. And, instead of completely federalizing the funding for that newly eligible group (as in the House bills), States would have to share in the cost. At least I BELIEVE that's what the section says. Read it for yourself. Making States share in the cost of providing care for Medicaid is a good thing, since they actually administer the programs. Of course, Governors hate this because they don't have enough money right now, and how would they come up with new money? The 55/45 split between Washington and States called for in the proposal could be altered so that federal taxpayers pay more, but States should have some skin in the game if Medicaid is going to be covering these people. And giving working people the option to join the exchanges (with subsidies) is a good thing. Who wants to be in Medicaid? Nobody that I know, rich or poor, unless there is no other option.
- Subsidies to Low income individuals (p 3-4) - Up to 400% of the poverty line, you'd get a refundable tax credit (i.e., whether or not you owe taxes). According to the Institute of Medicine, that's about 80% of the population of uninsured people. For example, at 400% of poverty, your premium payment would be capped at 13% of your income. For a family of 4, with a household income of $88K, (400% of poverty) that would mean a cap of $11K. Gov't would give tax credit for the rest. At least I think that's how it would work. Read it for yourself and let me know if I've got it wrong. jwagner@bethesda20817.net. Does that sound affordable?
- Revenue Provisions (p. 17) - I love the new tax on employers with high-cost health plans. The tax would ultimately be 35% of the plan expenses beyond the threshold. The tax would give employers incentive to reduce their health benefit costs. And I don't like the idea of subsidizing (with my tax dollars) the high-cost plans of the richer companies. On the other hand, the bill would completely eliminate the subsidy that employers get when they give Medicare-eligible retirees drug benefits. That's currently a 26% subsidy for every dollar of benefit. It's what has kept employers from dropping health coverage for Medicare-eligible retirees. Lots of employers might drop coverage for retirees. Is that bad? Medicare drug benefit is still available for all. So, I'm not sure whether it's bad or good. More thinking to come.
Jul 22, 2009
Become a Medicare Expert in 2 Minutes!
A little-known federal government Commission, MEDPAC, is a fount of information and advice about how to fix Medicare. (A lot of its advice I do not agree with!) It's staff is small (about 30 people) but its knowledge of Medicare is deep. The reason it's not known by most of us is that it works for the Congress, not as an educator of the general public. But, last week they put out a great Data Book: Health Care Spending and the Medicare Program, that summarizes very nicely exactly where our Medicare dollars go and why everyone in Washington with at least a smidgen of patriotism (versus self-interest) is semi-hysterical over the "Medicare problem." All you have to look at is the first 15 charts (in chapter 1 of the report) to understand why Medicare fee-for-service -- fee schedule -- medicine has NOT protected us from breaking the bank! The other 200 pages would be interesting for obsessive compulsives, but as imminent or new Medicare beneficiaries, my fellow classmates and I should at least know the basics. And, if we're still going to cocktail parties, we can spout a data point or two and be considered an expert!
Jul 7, 2009
Health Reform Kennedy Style
While I'm still pondering all the ramifications of having a public (Medicare-like) plan offered along side competing private plans under a Health Reform PROGRAM, I must share with you my reading of the first 200 pages (Title 1) of the latest version of the Senate HELP Committee's draft legislation. (I read so you don't have to!) (If that doc doesn't open, it means it's already been updated, so go to the Senate HELP Committee's home page to find the latest.)
One item I find particularly delightful is the provision to extend Medicaid eligibility to all individuals in households with incomes below 150% of poverty-- that's about $35K a year for a family of 4, covering about 18% of all households in the USA, according to Wikipedia.
On its face, that's not so terrible, since State Medicaid agencies are very very careful about how they spend money for Medicaid recipients. (States must pay for about 43% (on average) of total Medicaid spending. The Feds pick up the rest.) Indeed, some might say they're downright stingy! Here's the little detail: the legislation provides for the States to continue to administer the Medicaid program for those new enrollees, but this time the FEDERAL GOV'T will foot 100% of the bill. So, say you're the Governor of your state. What would you tell your Medicaid Director to do? Give 'em the BEST! Pay those doctors more! Stick it to the other 49! Of course, the other 49 will stick it too, so The COSTS, THE COSTS! They'll be out of control, and I'll probably want to qualify for Medicaid!
These are the kinds of little goodies that make me almost despair of ever getting affordable health reform. (Ironically, "Affodable Health Care" is the name of the HELP bill.) Bottom line: THANK GOD FOR CBO! I'm sure they'll cost it.
One item I find particularly delightful is the provision to extend Medicaid eligibility to all individuals in households with incomes below 150% of poverty-- that's about $35K a year for a family of 4, covering about 18% of all households in the USA, according to Wikipedia.
On its face, that's not so terrible, since State Medicaid agencies are very very careful about how they spend money for Medicaid recipients. (States must pay for about 43% (on average) of total Medicaid spending. The Feds pick up the rest.) Indeed, some might say they're downright stingy! Here's the little detail: the legislation provides for the States to continue to administer the Medicaid program for those new enrollees, but this time the FEDERAL GOV'T will foot 100% of the bill. So, say you're the Governor of your state. What would you tell your Medicaid Director to do? Give 'em the BEST! Pay those doctors more! Stick it to the other 49! Of course, the other 49 will stick it too, so The COSTS, THE COSTS! They'll be out of control, and I'll probably want to qualify for Medicaid!
These are the kinds of little goodies that make me almost despair of ever getting affordable health reform. (Ironically, "Affodable Health Care" is the name of the HELP bill.) Bottom line: THANK GOD FOR CBO! I'm sure they'll cost it.
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