Avik Roy, Medicaid, reader comments, etc.

Sometimes when I critique an element of a broader set of proposals or raise a question about some research it is mistaken for a wholesale dismissal of those proposals or a rejection of the research. If that’s my aim, I’ll say so. If I raise a narrow point or ask a pointed question, that’s my point, that’s my question.

Sometimes people think I’m engaged in an ideological fight. I’m not. I’m continually trying to understand our health system, how it works (and doesn’t ), for whom it works (and doesn’t), and how it might be improved. I don’t claim to have all the answers. Anyone who does is deluded or selling something. I also don’t think there is a unique solution to every problem.

I say all this because it relates to my recent blog-to-blog conversation with Avik Roy (his three posts, my two), on which some of my readers have commented. He responds in a new post to my comments and to those of my readers (yes, he quotes you guys). Avik finds it odd that I might want to spend more money on Medicaid. Of course I don’t want to spend more. I want everyone to have access to affordable, quality health care. The question is how to do it, and especially for those with low incomes and, in some cases, serious health needs. More to the point, how do we make things better for folks with politically realistic ideas and sooner rather than later (we’re talking death here)?

I will confess, I don’t know how to do it. If the literature Avik cited is to be believed, we can better assist Medicaid beneficiaries by making Medicaid more like no insurance at all. We can assist them even more by making it more like private insurance. That’s the unavoidable conclusion if one believes the studies. (The other interpretation is that they failed to sufficiently control for all the relevant differences between the three populations–the uninsured, Medicaid, and the privately insured. But I am not claiming that, I’m just mentioning it as a possibility. I haven’t read the studies, nor done a comprehensive literature review.)

Avik has another idea, or is it really different than either of the options I suggested?

I instead favor, as a start, what Mitch Daniels has accomplished with the Medicaid program in Indiana (before PPACA destroys it): subsidized health savings accounts combined with consumer-driven health plans. And Indiana covers people at up to 200% of the poverty line, compared to Obamacare’s 133%. Instead of covering more people, I would more heavily subsidize those at or below the poverty line, in order to bring Medicaid’s low physician payments in line with those of the private sector. Ideally, we would move to a modified version of the Swiss model, in which everyone purchases consumer-driven plans in the individual market, with graduated subsidies for lower-income households. (Bold mine.)

This sounds a lot like making Medicaid more like private insurance in terms of what it pays providers (that’s gonna cost something though!). I have no doubt that something more like health savings accounts (in general, higher cost sharing) is in our future. The Swiss model may well work and it is the direction we’re going elsewhere in the system, just not for Medicare and Medicaid (yet).

As for the HSAs in Medicaid, here’s the guts of it from the source Avik cites,

Healthy Indiana establishes a Personal Wellness and Responsibility (POWER) account valued at $1,100 per adult to pay for initial medical costs. This is similar to a health savings account (HSA) and is used to fund the deductible. The state pays 95 percent and individuals pay the rest.

Is this a money saver? Does it lead to better outcomes? How do Medicaid beneficiaries use that $1,100? I don’t know the literature on it so I’m asking honest questions here.

Avik goes on to write sentences I cannot disagree with.

Ultimately, the goal should be to minimize the number of people who require subsidized insurance. This requires comprehensive health reform aimed at reducing the cost of health care: de-linking employment from insurance; broadening the reach of consumer-driven care; creating a national insurance market; aggressive antitrust enforcement against providers; medical tourism; transparency; malpractice reform; and Medicare reform.

Which of these can pass Congress and in what form? That’s another serious question. I have argued that the ACA is about as much reform as the politics would allow. I want more. So does Avik. Get cracking legislators!

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