• One step back, two steps back

    So now that the Medicaid expansion is optional, some states are trying to see if they can make other parts of Medicaid optional, too:

    Within hours of the Supreme Court’s ruling on June 28, lawyers in the Maine attorney general’s office began preparing a legal argument to allow health officials to strike more than 20,000 Medicaid recipients from the state’s rolls—including 19- and 20-year-olds—beginning in October to save $10 million by next July.

    “We think we’re on solid legal ground,” Attorney General William Schneider said in an interview. “We’re going to reduce eligibility back to the base levels in a couple of areas,” he said. Maine, like some other states eyeing cuts, earlier expanded its Medicaid program beyond national requirements.

    Other states, including Wisconsin and Alabama, are expected to follow Maine’s lead, though there is disagreement over whether the high court gave the states such leeway. That could lead to battles between states and the federal government that could drag the health law back to the courts. New Jersey and Indiana also said they were evaluating the decision and did not rule out challenging the requirements.

    This is where we are? Trying to find ways to make more people uninsured? Even the math is crazy. If I’m reading that first sentence right, Maine is looking to drop people from insurance that’s costing them about $500 per person. Really?

    When the ACA was passed, it cemented in place whatever eligibility existed in individual states. Since they knew the expansion was coming, the feds didn’t want states to go bare bones in order to put even more expansion cost on the federal tab later. A number of states tried to cut their rolls, but were denied:

    Wisconsin recently sought to remove 60,000 people, including children, from its Medicaid rolls, but federal officials denied the move. The two sides ultimately reached a deal to strip 17,000 Medicaid beneficiaries.

    “I think the logic of the Roberts decision would reopen the matter,” said Mr. Smith, who was the top federal Medicaid official during the George W. Bush administration.

    Don Williamson, Alabama state health officer, said officials are looking at restricting eligibility for Alabama’s children’s health insurance program for the fiscal year starting Oct. 1 if federal officials officially lift the ban on changing eligibility. The move is aimed at closing a $15 million funding gap for the program, he said.

    The numbers we are talking here are so stunningly small when it comes to health care in general that it’s hard to imagine why this would be where we’d focus.

    I try to stay dispassionate on the blog. This is one of those times it’s hard. I’ve already received numerous people sending me this story in a gloating manner, as if it’s some “victory”. It’s not. For anyone.

    Medicaid isn’t “welfare”. It isn’t cash money. You can’t take your Medicaid and go buy cake. Or cigarettes. You can’t rest easy once you’ve got Medicaid. It doesn’t get you a roof over your head, or food on your table. It doesn’t even act as a disincentive to earn.

    It provides you with health care – if you need it. If you’re healthy, it doesn’t do anything. At all.

    And without it, you really can’t get that health care. Remember, we’re talking about people at the lowest end of the socioeconomic spectrum. If you’re single and work 30 hours a week for a whole year at the federal minimum wage, you make more than the poverty line. So if you don’t have Medicaid, you’re not getting health care. No asthma meds. No diabetes checkups. No mammograms or colonoscopies. No mental health treatment. No help with your insomnia, your rash, your heartburn, or your arthritis. Because even if you could go to the emergency room for these things, it wouldn’t be free.

    The cost to the US for health care is a real concern, yes, and trying to get it down is important. But the reason we’ve focused on it so much the last few years is because many people felt that the access problem had been improved dramatically. If we’re really going to start trying to go backwards on that front before we’ve even gone forwards, then I have no idea what’s going on at all.


    • You speak about Medicaid as if it is a Constitutional right.
      It’s an entitlement program funded by the government, both federal and state, and controlled by law.
      Laws can change.
      And right now, states are trying to save money so they don’t have to continue to raise taxes.
      It’s unfortunate that Medicaid recipients aren’t required to pay some sort of co-pay for their care. When I spent 3 months in Haiti 30+ years ago, the missionary medical clinic in Limbe even charged a token fee because they understood that free care leads to unlimited demand.

      • This comment is truly outrageous. Since when is a good policy only defined by it’s explicit constitutionality?

        I find it incredibly hard to believe that states are driven to the point where they have to cut Medicaid rolls in order to balance their budget. As Aaron noted, these individuals in Maine cost the state about 500 dollars each. Do you have any inkling as to how small that actually is? In FY 2011, Maine’s total revenue was about 2.8 billion*. That 10 million cost is less than 1% of that revenue.

        What Maine is doing stinks of political opportunism of the absolutely worse kind.


        General Fund Revenue Forecast

        • Wow, and where does the state get it’s money? Taxpayers.

          • These taxpayers are so uniquely holy that they cannot pay that less than 1% of total expenditures on something that clearly leads to a better society?

            Even assuming there is only a 1% shortfall in the budget, are you really assuming that every single other avenue for cost reduction was explored? Are you taking the stance that the state government of Maine is 100% efficient? Are you taking the stance that Medicaid provides zero value?

            I’d be a libertarian if they weren’t so darn fanatical.

      • I don’t think increasing Medicaid cost sharing will help very much, for a few reasons:

        – Its copays just can’t get very big, as established in the landmark case Blood v. Turnip.
        – Health care doesn’t get unlimited demand even when free; how many people get gratuitous colonoscopies? (Do the TIEers have numbers on that?)
        – Increasing copays (in any population) tends to result in people simply using less care overall, and the foregone care has basically no relationship to its effectiveness (as seen on this blog). That is, it doesn’t necessarily lead to more bang for the buck, just less bucks.

        • I agree, Corey.
          There seems to be a pervasive feeling that “free” healthcare will lead to rampant overuse. This ignores the fact that most people (except Munchausen) are happy to avoid the medical system unless they are in pain. It also ignores the ancillary costs of medical care (time lost from work or family, medical system inflicted pain, etc.).
          People speak of “moral hazard” of having insurance leading to greater use of the insurance but the abuse is not by patients, it is by doctors, hospitals, etc. who feel free to overuse dx and tx and to overcharge for these services since “the insurance company is paying”.
          The only thing that happens when you create financial barriers to access is that people don’t get necessary care and their health suffers.

    • This is just more class warfare by the rich.
      Cut taxes for the rich and benefits for everyone else.
      “…the rich get richer and the poor get poorer, ain’t we got fun? “

      • I think the only solution you would agree with is to tax “the rich” at 100%, and keep taxing until the Chinese flag rules our shores.

        • I’m approving this only to prove that I get comments and emails like these.

        • Ron,
          These are your thoughts and words, not mine.
          Taxes on the rich today are lower than they have been since WWII. Clinton had a budget in surplus and there was none of this talk of cutting benefits until the Bush tax cuts, wars, and Medicare part D.
          If you are interested in my opinion, I think putting taxes back up to the level under Clinton and a few other changes (like removing the income limit on Social Security and Medicare contributions so that the rich are not taxed at a lower rate) would fix our budget problems and give us plenty of money to preserve the social safety net.
          However, the Republicans are using the deficit as an excuse to cut benefits for everyone but the rich and they won’t consider any tax increase (or even closing tax loopholes such as the ones used by Romney to cut his tax rate to 15%).
          This is class warfare by the rich (who have purchased the Republican party… Citizens United is the capstone).
          “It’s only class warfare if we fight back”

          • And the bottom 50% are paying less in income taxes than after WW2. Should we also start requiring them to pay more taxes?

            • Could that be because the bottom 50%’s percentage of GDP is at its lowest since ww2? I’ll gladly give a source if needed, but almost no one disputes the increasing inequality in the US.

          • For the record, there is no upper limit on taxes for Medicare like there is for SS. And if you simply increase the cap for SS then you’ve truly made it a welfare program. You can make it more progressive though.

    • I wish you and Austin would once and awhile try and balance your posts.

      The people proposing these cuts are not conducting “class warfare” or evil – they are concerned about finding a balance between costs and benefits that we can afford and sustain…

      I believe that walk in clinics can and do fill a good deal of the needs for these folks. Our daughter makes barely more than the minimum wage and is not eligible for either medicaid or insurance. She visits a local clinic 4 or 5 times a year as needed and can afford the cost of these visits.

      • This is Aaron’s post. If you have a comment on one of mine, please raise it there.

      • I don’t think the words “class warfare” have ever appeared on this blog. Nor did I accuse anyone of “evil”. And please don’t lecture me on hard choices. I’ve written on them many, many times. I think hard choices exist; I don’t think these are examples. If others disagree, they are free to write about them.

        Plus, you may “believe” that walk-in clinics can fill in the needs. But (1) there’s little evidence of that being so and (2) my anecdotal experience has shown me that’s not the case. I don’t hold up (2) as proof, but to add to the fact that what you’re stating is a belief, not something known.

        Your daughter is lucky. I doubt she has a chronic illness, given your description. Your experience is, unfortunately, not everyone’s.

        • I will confess to being a regular – but not a complete reader.

          And I have as I have said before, tried to listen carefully and learn from this blog.

          But I stand by my earlier post in feeling at times that you can be a bit one-sided in asserting things like…

          “And without it (medicare), you really can’t get that health care”.

          I suggested in response that walk in clinics could fill some or all of this need.

          I would love to read any studies you might be able to point me to that deal with this – and I promise to do my homework and try and seek this research out on my own.

          Perhaps we might agree to rewording my original to…

          Perhaps walk-in clinics might play a role in meeting this need in the future if certain conditions are met [and have some data on what these conditions would be].

          I would add an anecdotal observation that when you call our doctor’s office and are greeted by the omnipresent electronic receptionist her first advice is “if this is a real medical emergency, hang up and call 911”.

          I wonder how many lay folk know if an emergency is “real” and if there might not be an intermediate step before mobilizing the police and ambulance.

          • First of all, we’re discussing Medicaid, not Medicare. Those aren’t the same at all.

            Second, walk in clinics CANNOT provide care for everything. Just look at the list I gave off the top of my head. No colonoscopies. No mammograms. No mental health care. No diabetes checkups. And much much more. Walk in clinics are great if you have a sore throat. Not if you need your diabetes monitored.

            I’ve written about minute clinics. They do have a role, perhaps. They don’t replace Medicaid.

            P.S. You also need to seriously consider the fact that a person making less than the poverty liner might not be able to afford even a walk in clinic. And, in most states, they can’t get Medicaid.

    • Aaron,
      It is truly unfortunate that some of your blog participants are communicating with a “gotcha” mentality. This very real issue is a non-partisan matter (or should be) of social and economic policy in crisis. Those who are using it as a political football are, in effect, throwing our most vulnerable populations under the bus to gain advantage in a game that has lost sight of social ethics and moral values.
      It is true that the money to pay for health coverage for all citizens is a barrier to implementation. There is no way around the fact that we are swimming in unsustainable debt and must make hard decisions. I would suggest that instead of raising the eligibility bar for Medicaid beneficiaries, we try having a discussion about the basic levels of benefits that should be provided. I disagree with the actuarial approach (76% of actuarial value for the lowest income tier), that is just counter intuitive. Rather I would prefer to look at evidence based values for the most effective forms of preventative care as well as the delivery method. Many if not most preventative services can be provide in a periodic neighborhood clinic setting. Health departments can provide routine vaccinations for adults at a very low cost that would not necessitate an office visit. If you look at the preventive screenings recommended by the PPACA they could be delivered more cost effectively than individual office visits. Office visits could be limited to symptomatic needs. There are more examples but certainly a different forum with professional experts would be more appropriate.
      It is true that some states have over-reached on benefit levels but the answer (in my opinion) should be looking for more cost effective delivery solutions, not stripping out current beneficiaries who have qualified under already stringent criteria.
      Of course there will be cries of equality of treatment environments. My response to that is, yes, money buys a more elegant heath care environment, but lack of money should not prevent basic, evidenced based preventative and health care treatment albeit, the art on the wall and the chairs in the waiting room may not be of the same caliber.

      • I agree with much of this, and have posted on it a number of times. Anyone who thinks that I don’t realize there are hard choices to be made isn’t reading what I write.

      • That’s a good post.
        Looking at both sides.

    • As much as I would love to involve the states in tailoring their health care systems to satisfy local needs and desires, at this point there’s really no feasible option other than federalizing the entire damn thing and telling the states to go pound sand.

    • Your anger is justified and you are articulate in your expression of it. Bravo!

    • “The numbers we are talking here are so stunningly small when it comes to health care in general that it’s hard to imagine why this would be where we’d focus.”

      Unfortunately, “health care in general” is not the relevant comparison — the truly appropriate comparison is with the state budget of Maine. Even for a state, $10 million is a lot of money, and if there is a budget gap of say $100 million then cutting Medicaid might very well be an attractive or sensible policy from a financial standpoint. It really depends on the specific numbers, but those numbers have to come from the government of Maine. Comparing the $10 million to the overall cost of healthcare doesn’t really make a lot of sense.

      Of course I agree with you that this approach has terrible consequences from a human standpoint, and the people who lose their Medicaid coverage will suffer. But if there is no money to fund this coverage, then it simply won’t be possible. I suspect that we will see many more such reports in the news over the next few years as the ACA has to contend with the fiscal constraints of the real world rather than the best-case scenarios that formed the initial justification.

      • Incidentally, I threw out the figure of a $100 million dollar shortfall as a hypothetical example. But a quick Google search shows that this is not far off the mark, and the real budget deficit is $80 million dollars. So saving $10 million is actually a substantial chunk of that shortfall.

        None of this should be interpreted to mean the cuts are justified, or even a good solution to the problem. Instead, my only point is that if we are going to argue against this policy, it needs to be on the basis of the particular situation of Maine, and comparing these cuts to health care expenditures in general is not helpful.

    • “No diabetes checkups. And much much more. Walk in clinics are great if you have a sore throat. Not if you need your diabetes monitored.”


      “CVS Caremark plans to further expand its MinuteClinic footprint from present 650 to 1,000 by 2016. MinuteClinics grew revenues by 22% last quarter and achieved break-even profitability in 2011. Apart from offering a convenient way for people to get common vaccinations, CVS’s MinuteClinic also focuses on preventive care, diagnostic tests and monitoring of chronic conditions such as diabetes, hypertension and high cholesterol.”


      • Yeah, I don’t see anywhere in there where it shows how they provide care for free to those who can’t afford it. Thus, my point.

        • One of the problems I often have in this debate [not just here but seemingly everywhere] is how the word “free” is often used when “taxpayer-funded” would her more accurate.

          Does the state removing these folks from Medicaid preclude a state – say Texas, from creating a program to provide low income individuals with access to a basic bundle of services for free – say through a walk-in clinic or clinics. Of course such a program might not provide free contraceptives or annual mammograms for women over 40.

      • Oh wait, I see. You were playing your usual “gotcha” role where you try to find one small point to refute instead of engaging in the larger argument at all. Well done!

        You are correct that Minute Clinics claim to to diabetes care. I await any proof that it’s good or that it’s more cost-effective.

        • I was just using factual information to refute a claim that was demonstrably incorrect. Per your statements regarding your evidence based blogging standards – I believe you made comments encouraging readers to do so.

          They clearly do not provide care for free for persons who can’t pay their fee – but that wasn’t the claim being advanced above. For that matter – providers who accept Medicaid patients do not do so for free – they do so in exchange for a fixed fee that the government pays on their behalf.

          It would indeed be very interesting to compare how walk-in clinics that treat low acuity, chronic conditions like diabetes, high blood pressure, high cholesterol, etc perform relative to institutions that accept medicaid patients in terms of cost, quality, and patient satisfaction. If there haven’t already been well-designed and executed studies that address these questions, hopefully we’ll have that data eventually.

          • My point was walk in clinics “don’t replace Medicaid”. The claim was “walk in clinics CANNOT provide care for everything”. I then listed a bunch of things in rapid succession. The real list is likely enormous. But rather than engage the claim, you did the usual and proved that one of the things I mentioned might actually be covered, thus… what? Scoring a point? If that was your intent, again… well done!

    • Maine got a Tea Party governor after an independent split the moderate vote. His first move was the get rid of a great Diego Rivera mural in the saying it was ‘communist.’ He’s gone downhill from there.

      He did implement some ObamaCare features, like opening Maine’s health insurance market to insurers from other states, but he claimed with his usual bombast that it was his Republican free market ideals and not evil, extortionately expensive, socialist ObamaCare.

      • Correct me if I’m wrong. The ACA did not open up interstate competition (not sure of the best terminology).

    • Regarding hard choices, we have two

    • Regarding difficult choices, we have two very serious issues that demand resolution. The first is our unsustainable debt and the second is the unsustainable state of our current healthcare system.
      From a healthcare perspective, we see a lot of comparisons with other countries that spend less on healthcare but have better results. I’ve heard all of the arguments (we have more immigrant babies with no pre-natal that drag down our infant mortality rate, we have more immigrants drawing down on the system ect. In fact, most of this is just extraneous noise. The real reason other countries spend less is they have fewer high cost, high tech machines and they use them more prudently. Fewer machines (MRIs ect.), also mean longer wait times for access and any way you slice it, long wait times are just a form a rationing.
      In addition, physicians do not make the kind of income our specialist do.
      One argument I am not conversant on, is the notion that the United States invests the most in the development of drugs and technology and hence we bear the cost while the rest of the world benefits. I have no idea if that theory has any validity at all. Anyone care to comment?

      • This blog’s FAQ on why health care costs are so high shows that the amount we as a nation overpay for drugs (defined as how much more we pay than other developed countries, adjusted to reflect that we’re richer than they and so might legitimately spend more) is more than twice the pharma industry’s annual R&D budget. (Or, if you prefer, more than the R&D and marketing budgets put together).

        Since reading that I’ve been advocating the obvious yet politically impossible solution to anyone who will listen:

        Assuming the cost of drug manufacture is less than that of R&D, we could publicly fund pharma R&D at current levels (so no loss of innovativeness), literally give away the drugs, and still come out ahead.

    • Not a lawyer but why the freedom now to gut Medicaid because of the recent Supreme Court ruling? Is this a game of chicken? States participate in Medicaid “voluntarily.” Don’t the Feds set up at least minimal standards for giving their contribution? Couldn’t the Feds threaten to withdraw their non-ACA dollars if the states eviscerate current Medicaid?

      It’s not like the recent ruling said states get the ACA money and the Feds can’t tell them what to do. It just said the states don’t have to participate in the expansion and be penalized by having non- ACA Medicaid money withheld.

    • Is Medicaid a disincentive to earn, if you’re sick? Getting a job that doesn’t provide insurance (and many don’t, at the low end) could leave you significantly worse off financially. (I know a family that was in this situation in the 80s; admittedly the landscape has changed a lot since then).

      I figure if anyone knows the numbers on this, it’s you guys.

    • http://economix.blogs.nytimes.com/2012/07/03/will-states-expand-their-medicaid/

      Counterpoint on whether Medicaid affects employment. Confession, I only read the blog post and not the testimony he links to.

      • First of all, my piece isn’t about the Medicaid expansion, it’s about taking people off current Medicaid. There’a a difference. You link to a piece about the expansion. Moreover, the people on current Medicaid are almost all below the poverty line, and the piece you link to explicitly says:

        (The expansion could increase employment among the relatively small fraction of able-bodied adults who already earn less than the poverty line but would reduce employment among the much larger fraction who so far are at or above the poverty line, for a net employment reduction.)

        It’s not a counterpoint.

    • Specific to your statement that Medicaid is not a disincentive to earn, I think it is.