• Government health care for all?!?!!

    In the past few years I’ve scoffed at those who predicted that a failure of the ACA would somehow lead to single payer. After all, wishing won’t make it 60. But as I’ve watched the private-based exchanges fail so miserably, while Medicaid has quietly done gangbusters comparatively, I wonder:

    Some states are signing up tens of thousands of new Medicaid enrollees in the initial weeks of the health law’s rollout, while placing far fewer in private health insurance—a divergence that suggests Medicaid expansion may be a larger part of the law than expected.

    In one sense, the Medicaid figures are good news for the Affordable Care Act’s advocates, who hoped the law would reduce the number of Americans without health insurance.

    But the predominance of Medicaid enrollees so far could also fuel criticism that the law will lead to a greater government grip on the health-care system, instead of leaving room for private health insurers to grow.

    Well, if any conservatives worry about that last statement, they would want to get those exchanges working, no? Instead, I see people rooting for their failure.

    The numbers are hard to deny:

    In Washington state, one of the states that operates its own exchange, 87% of the 35,528 people who had enrolled in new insurance plans from Oct. 1 to Oct. 21 were joining Medicaid plans, according to state figures. By Thursday, 21,342 Kentuckians had newly enrolled in Medicaid, or 82% of total enrollees. In New York, about 64% of the 37,030 people who have finished enrolling were in Medicaid.

    Some states like Maryland, Washington and California are using aggressive outreach to get people into Medicaid, including contacting those who are already on other programs such as food stamps, said Matt Salo, executive director of the National Association of Medicaid Directors.

    “When you actively go out and aggressively target people, they sign up,” he said.

    Navigators would help people similarly get into the private-insurance exchanges. Opponents of the ACA have tried to all but eliminate them, though.

    Getting Medicaid is often simpler than private coverage, especially since many states have cut back on paperwork. Medicaid enrollees can go to state offices to sign up and avoid the federal HealthCare.gov portal, which currently can’t transfer information about Medicaid-eligible people to the states. And Medicaid enrollees typically have fewer decisions to make on deductibles, prescription-drug plans and doctor networks.

    “There are no comparisons between those processes,” said Kip Piper, a Washington-based Medicare and Medicaid industry consultant. “It’s not like comparing apples to apples or even apples to oranges. It’s apples to poodles.”

    For years, single-payer advocates have argued that Medicare-for-all would be simpler than the ACA. I’m hearing that sentiment from more and more people recently.


    • Who gets the blame if ACA fails: the conservative opponents or the neo-liberal proponents? This is a debate worth having one day, but not a debate worth having today. Dr. Carroll is correct that it’s a debate taking place today, and taking place on both the liberal side and the conservative side. And it’s a debate that puts neo-liberals on the defensive. I have seen the enemy and it is us! The article in the current issue of National Affairs by Steven Teles, Kludgeocracy in America, is compelling. Liberals pay a very high price (in terms of the erosion of public support) for the type of hidden government support in programs like ACA and so many other neo-liberal programs. Arguably, it is the rent seekers who derive the most benefit, not the intended beneficiaries. Maybe. But now is not the time for a circular firing squad.

    • It will be interesting to see how happy those being enrolled into Medicaid are a year from now – and how they are doing health wise. Hopefully someone is prepping to do this sort of study.

      It seems odd that such a large number of folks are out there who are Medicaid eligible – but had not already enrolled.

      One possible hypothesis is that they knew they were eligible, but were hoping they might get into a “better” plan by applying through the exchange.

      I have heard – but not seen verified, that these folks are being “forcibly” enrolled – perhaps someone can verify – if so what are the implications of forced enrollment?

      • There is thorough commentary and many links to the Oregon Medicaid study results, as well RAND health insurance study results on this website. These posts, and others, might inform your first comment. Use the search tool.

        Also unsurprisingly, “Medicaid expansion” expands the scope of the population eligible for Medicaid…

        • Brian,

          I am familiar with the studies and related posts on TIE and elsewhere. But I am wondering if the same dynamics are at work here. I know for example that in Oregon a rather large percentage of those who won the lottery – got Medicaid eligibility – did not follow through and sign up.

          I am just thinking this particular sample – larger than Oregon – might have sufficient “power” to resolve some of the unresolved findings…

          Would hate to see this opportunity wasted…

      • Why do my patients worry that they will lose Medicaid for themselves when their minor children reach 18, if the program is so terrible? Why are they happy when they qualify? I guess they don’t realize what a terrible program it is without the Republicans to inform them.

        • Stella B,

          I am not taking a position on whether Medicaid is good or bad – I am just curious as to why there seem to be large number of people qualified for Medicaid who seem to have no desire to use it.

          My personal – poorly informed – opinion is that it is program the can work well for some – should they be at the right place [have a Doctor willing to take them on as a patient] and have the right set of needs – basic personal/family care.

          I did see a post earlier today that one thing that remains a problem is the files being sent to the state Medicaid agencies contain a number of folks who are already covered – along with some who may in the end not be eligible,

          • LL, there have always been a lot of people who are eligible but not enrolled in Medicaid. My sense – and I don’t have data at y fingertips to support this but suspect it’s out there – is that many of these people are relatively young and infrequent users of the health care system. Once they start racking up high costs – with an inpatient stay, for example – then the hospitals work hard to get them enrolled. This is where some of the studies that purport to show that Medicaid is harmful go wrong – they fail to adjust for health status. People in Medicaid, especially the high users, are sicker than the uninsured population.

            Also, I suspect that increase in Medicaid enrollment is coming only partially from the eligible but not enrolled contingent. It’s more likely a result of Medicaid expansion, especially in large states.

    • and we are comparing cumulative numbers of people added to medicaid on state health exchanges against numbers of people buying individual policies on state health exchanges for what purpose……

      • Well if the goal was – is – to get everyone eligible for Medicaid enrolled I think there are [were] a lot more efficient ways of doing that than building a $Billion web site.

        And this could have – perhaps arguably should have – been done BEFORE passing the ACA. Nothing was preventing the states from doing this – and Federal legislation to support this would have probably been easier to pass than the entire “train wreck”.

    • “For years, single-payer advocates have argued that Medicare-for-all would be simpler than the ACA.”

      I’m sure it would be. And having a single government-run food store would be simpler than the sea of private companies with their own supply chains.

      • Yes, the Canadian system shows that for medical care government-run health insurance gets better patient outcomes with lower costs. look at the Healthcare Now website for a comparison of US/Canadian outcomes for those over 65! It is truly amazing how true single payer has worked so much better than the US-form of Medicare.

    • Whether or not Health.Gov is a success should be trivial. The law is passed, the insurance policies and subsidies available, the only issue is the ability to match a buyer with a policy and, possibly, a subsidy.

      Both insurance companies and the Gov’t have long experience with doing just this. Health.gov is a red herring.

    • At the risk of violating my cautionary comment about a circular firing squad, I must make a comment about “complexity”. When the administration decided not to adopt federal (uniform) standards for health insurance, I was disappointed for many reasons, not the least being that federal standards would make the “choice” for a plan so much less complex. I was also surprised, surprised by the silence among the health care policy wonks. Was it because they weren’t surprised by the decision, they agreed with the decision, or they wanted to be team players. It wasn’t until I read an article, I believe written by Professor Bagley, that the decision did come as a surprise to health care policy wonks; indeed, many were gearing up for the project of designing the standards. Some have speculated that the decision was politically motivated: the administration didn’t wish to fight another battle over the “government takeover” of health care or denying “choice” to consumers. Some have speculated that the decision was motivated by the concern over the death spiral, that not having federal (uniform) standards would allow for greater “choice” (a euphemism for insurer risk management). Whatever the motivation for the decision, once the federal exchange gets past the “technical glitches” and consumers can get beyond the log-in page, they will face “choices” that will be mind-numbing and, I fear, paralysis inducing. Some have argued that this is no different from the “choice” allowed Medicare beneficiaries with respect to the drug benefit. I disagree. Most Medicare beneficiaries are regular consumers of health care and drugs, and can readily determine which plan includes the drugs they use. Not so with young and healthy consumers, who wouldn’t know which plan, with which benefits, would be best for them. I don’t. Sure, for the already injured or sick, they may know something about the “choices”, but not the typical consumer. Of course, the decision not to adopt federal standards was but one of many decisions in the design and implementation of the neo-liberal version of health care reform. Maybe the term “design” is giving too much credit. My point is that the neo-liberal solution may not be the culprit, but rather the decisions made in its design and implementation.

      • When the administration decided not to adopt federal (uniform) standards for health insurance, I was disappointed for many reasons, not the least being that federal standards would make the “choice” for a plan so much less complex.

        One of my often made points is that state governments’ regulations can and are working against the PPACA. As long as the federal Governments are paying for so much that sate governments can leave bad regulations in place.

    • Look, of course signing up for Medicaid is simpler. Qualify? Congratulations, you’re signed up. End of story.

      The health exchanges require more deliberation — even once you know you qualify for some tax credits — and some number crunching. Most people aren’t great at the actuarial math and will take some time to dwell. Consider how employers need to nag their workers to sign up for a plan nine times every year during open enrollment. (Maybe this is just my experience.)

      You’d expect signups for private care to be a little slower, and I’ve read that was the experience in Massachusetts. That doesn’t mean Medicaid is better all-around.

    • How ironic – talk about the law of unintended consequences – that the moth eaten plan imposed by a Dem Congress with the intention of forestalling the impetus for SP might well result in increasing that impetus – poetic justice (smile…)

      And then there’s the irony that in seeking to obstruct the ACA, out of fear that it would lead to SP, its right wing opponents have helped highlight its fundamental flaws to the point that SP looks better and better (smile again …)