Tag Archives: Medicaid

The Closer You Look, The Meaner It Is

If your eyes glaze over at the prospect of getting down “in the weeds” of the Senate healthcare bill, Josh Marshall’s summary really tells you everything you need to know:

It has always been crystal clear for numerous reasons that the Senate health care repeal bill would be the like the House bill, both versions, just as it will be like the final bill that emerges from a conference committee. McConnell and Ryan knew that ball hiding about scores and legislative language would prevent reporters from saying this: Around 24 million Americans will lose their coverage, everyone will go back to the era of pre-existing conditions restrictions and lifetime limits. The freed up money will go to a big tax cut for the very wealthy. You didn’t need to see the legislative language to know this. It’s been a failure of journalism to pretend otherwise.

If, however, you want several specific compelling reasons to oppose this travesty, there are any number of reports and commentaries that can help. For example, we learn about several “buried” provisions from an article in the LA Times, in a column that describes the bill as a “poorly-disguised massive tax cut for the wealthy, paid for by cutting Medicaid — which serves the middle class and the poor — to the bone.” Then there’s this:

States will have more authority to reimpose lifetime and annual benefit caps and eliminate essential health benefits. This may be the most insidious provision of the repeal bill, and certainly is the most deeply hidden.

As several Governors–including Republican Governors– have noted, this grant of authority to the states will almost certainly be used, because the deep cuts in Medicaid and other federal funding will leave the states no choice.

The Affordable Care Act also had state waivers designed to allow for innovations, especially in state Medicaid programs. But under the ACA, those waivers could not  lead to fewer people being insured, or to the imposition of higher out-of-pocket expenses. The Senate bill repeals those limitations.

Under the measure, the secretary “must” approve a waiver request as long as it won’t increase the federal deficit. As a result, states would be able to eliminate the essential health benefits that all health plans must provide under the ACA — including hospitalization, prescription coverage, maternity care and substance abuse and mental health treatment. Since only essential health benefits are subject to the ban on lifetime and annual benefit limits, high-cost patients such as cancer victims and sufferers from chronic diseases could permanently lose their benefits in the course of their treatment.

And then there’s pre-existing conditions. As the Times reports,

Protection for people with preexisting conditions is destroyed. Senate Republicans claim in their talking points that the measure protects people with preexisting conditions from being denied coverage or priced out of the market. Don’t believe them…The Senate bill will open the door to states forcing people with preexisting conditions into segregated markets that will lead them to pay far, far higher costs than everyone else….This bill will bring the country back to a system in which insurance only works for the healthy, and the sick can’t afford the coverage they need.

There’s lots more. Older Americans will get hosed; under this bill as currently drafted, older Americans could be charged five times what younger, healthier Americans will pay. Meanwhile, the biggest tax cut for the rich is retroactive; a millionaire who already had booked a $1-million gain on a stock sale, for example, would collect a $38,000 benefit.(Even the Wall Street Journal was aghast at that one.)

And most despicable of all:

In fact, all the measure’s tax cuts taken together, valued at about $700 billion over 10 years, would be almost entirely paid for by the bill’s elimination of Medicaid expansion in the 30 states and the District of Columbia that accepted it.

The bill defunds Planned Parenthood. It cuts Medicaid so drastically that hundreds of thousands of elderly Americans will no longer be able to go to nursing homes, and rural hospitals that depend upon Medicaid will close. It will strip coverage from more than twenty million people, and take us back to the days when people had no choice but to use emergency rooms for primary care. The medical cost curve, which had been coming down under the ACA will once again rise more rapidly than the rate of inflation.

And why? To further enrich the already wealthy–and not so incidentally, to destroy the legacy of America’s first black President.

 

Making America Sick Again

With the introduction of its proposed budget, the Trump Administration has continued its effort to cut the ground out from under all but the wealthiest Americans–and especially from under the people who voted for Trump.

Fortunately, that budget displays the stunning ineptitude that is a hallmark of this Administration (Hey–what’s a two trillion dollar math mistake among friends..?) and is unlikely to pass.

We often hear exhortations to “follow the money,” or to “put your money where your mouth is.” Those phrases reflect an undeniable truth of human behavior: whatever our rhetoric, where we commit our resources shows our real priorities.  Trump’s budget not only makes his priorities painfully clear; it reflects his callous disregard for struggling Americans, including those who voted for him.

Time Magazine has detailed the consequences of the savage Medicaid cuts proposed by the Trump budget. Nearly one in four Americans–and 42 percent of Trump voters– rely on Medicaid. The budget assumes passage of the deeply unpopular Obamacare replacement passed by the House and currently pending in the Senate; that measure–which the CBO calculates would cost 23 million Americans their health insurance– cuts Medicaid funding by $839 billion over the next decade. The budget proposal reduces Medicaid by an additional $610 billion.

Those cuts endanger medical access for 74 million Americans.

Medicaid reaches far beyond able-bodied adults out of work, despite the proposal’s rhetoric. The elderly and disabled account for around 60% of Medicaid’s expenditures, with the disabled, including the mentally ill, accounting for a full 42% of spending.

The program is the country’s largest funder of long-term care expenses, covering 40% of the costs, as well as more than 60% of all nursing home residents. For Baby Boomers nearing or past retirement age, these funds are crucial: As MONEY has previously reported, nursing homes for the elderly cost an average of $80,000 annually, and those expenditures aren’t covered under Medicare, the health program for seniors over 65. In fact, because Medicaid absorbs high healthcare costs of people with expensive conditions like dementia, it has kept private insurance around 7% lower than they would be.

Slashing funds also disproportionately affects women and children: one-half of births in the U.S. are covered by Medicaid (that varies widely by state—in Louisiana, 65% of births are covered by Medicaid, according to the Kaiser Family Foundation). The Children’s Health Insurance Program, which covered more than 8.4 million children in 2015, would also see its budget significantly reduced, according to Joan Alker, Executive Director of the Georgetown Center for Children and Families. Medicaid also provides essential health coverage for low income women, particularly women (and children) of color.

And of course, the budget continues the Republican war on women and women’s health by defunding Planned Parenthood–effectively eliminating preventive care (pap tests, breast cancer screenings) for most poor women.

Pointing to the cruelty of this proposal is unlikely to move lawmakers for whom tax cuts for rich people are the highest priority, but you would think they might realize that such a wholesale assault on access to preventive care would wildly increase overall medical costs. (The old adage “penny wise, pound foolish, comes to mind.) Trump’s budget would throw people back to the tender mercies of the emergency room, return us to the days when medical costs and nursing home fees bankrupted families, and ensconce a system in which healthcare is simply a consumer good, available to those who can afford it and too bad for the rest of you.

Destroying Obamacare and slashing Medicaid aren’t even the end of the story: the proposed budget also “severely cuts funding for science and public health agencies, including a $1 billion cut to the National Cancer Institute.”

Notably, the National Institute of Health’s budget would be slashed from $31.8 billion to $26 billion. The Center for Disease Control and Prevention would face cuts of more than $1 billion, including a $222 million decrease in funding to the chronic disease prevention programs, which help people with conditions like diabetes, heart disease, and obesity.The National Science Foundation would face a decrease of $776 million.

Welcome to dystopia.

Those Pesky Facts

One of my earliest research projects when I entered academia focused on an element of the “Personal Responsibility and Work Opportunity Reconciliation Act of 1996,”  (PRWORA) aka welfare reform. I looked at the consequences of the measure’s invitation to (undefined) Faith-Based Organizations to help government agencies provide welfare services.

Needless to say, the “armies of compassion” envisioned by George W. Bush failed to materialize, since the invitation was based largely on fanciful–indeed, “faith-based”–beliefs about the capacities of the invitees.

I mention this in order to explain my heightened interest in a recent “spat” between Peter the Citizen and Arthur Brooks.

In “The Dignity Deficit: Reclaiming Americans’ Sense of Purpose,” Arthur Brooks, president of the American Enterprise Institute (AEI), emphasizes the importance of work requirements for welfare programs and suggests that the 1996 welfare reform law provides a model for other safety net programs:

Putting more people to work must also become an explicit aim of the social safety net. Arguably, the greatest innovation in social policy in recent history was the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The PRWORA, which became synonymous with the phrase “welfare reform,” made several major changes to federal policy. It devolved greater flexibility to the states but established new constraints, such as a limit on how long someone could receive federal welfare benefits and a work requirement for most able-bodied adults.

As Peter points out, PRWORA changed a number of programs, but what Brooks is lauding is TANF (Temporary Assistance for Needy Families). Peter, like Brooks, is a political conservative; he was a  former member of the Reagan Administration whose “portfolio” was welfare programs.
And he begs to differ.

For the past two years, I have been writing papers as a citizen to highlight TANF’s many problems. My hope is that conservatives will adopt more “rigor” in their assessment of the 1996 law and use evidence rather than ideology in developing reform proposals.

Brooks claims that TANF reduced poverty, and that its “lessons” about “the dignity of work” should be extended to other poverty programs. Peter convincingly demolishes the first assertion, and provides copious data to prove his point. Although he clearly agrees that there are “lessons” to be learned,  the content of those lessons differs significantly from what Brooks suggests.  I really encourage readers to click through and read the entire paper. The exchange illustrates the difference between ideology and intellectual integrity–between seeing what you want to see and seeing what the evidence shows.

What really caught my eye, however, were the following observations (emphasis mine):

TANF’s block grant structure creates a situation in which states don’t have the resources to run meaningful welfare-to-work programs, as the amount is not adjusted for inflation or demographic changes. This problem is exacerbated when state politicians divert scarce funds to plug budget holes….

In fiscal year (FY) 2015, just 25 percent of TANF funds were used to provide basic cash assistance and just 7 percent were for work-related activities, despite the fact that the number of poor families with children was higher in 2015 than in 1996. In many states, TANF has become a slush fund used to supplant state spending and fill budget holes…

Since TANF’s inception, states have used tens of billions of federal TANF dollars to simply replace existing state spending. For example, Jon Peacock of the Wisconsin Budget Project explains how “a significant portion of the federal funding for … assistance is being siphoned off for use elsewhere in the budget, to the detriment of the Wisconsin Works (W-2) program and child care subsidies for low-income working families.” It would be one thing if poverty had declined in Wisconsin since TANF’s enactment, but the poverty rate for children in Wisconsin grew from 14.3 percent in 1997 to 18.4 percent in 2011. If the supplanted funds were used to fund other programs for poor families, the practice would be less harmful, but that doesn’t seem to be what happens in Wisconsin. According to Peacock, “That shell game uses TANF funds to free up state funds [general purpose revenue] (GPR) to use for other purposes, such as the proposed income tax cuts.”

Trump’s budget–which combines utter fantasy with gratuitous cruelty (eliminating Meals on Wheels!?)– contains deep cuts to Medicaid and proposes to  fund what’s left through block grants, facilitating–and probably ensuring– precisely the sort of “shell game” that the states have played with TANF.

Anyone who thinks that the monies sent to the states via Medicaid block grants would all be applied to the costs of providing medical care for poor people is smoking something, and it’s hallucinogenic.

 

 

 

The Unarguable Benefits of Universal Healthcare

As political posturing over the Affordable Care Act (aka “Obamacare”) continues, the fiscal and social benefits of expanded access to healthcare become steadily more obvious.

The journal Health Affairs recently reported an 8 percent increase per year in the number of early-stage colorectal cancer diagnoses since passage of the ACA. Extrapolated across the country, the researchers estimate the ACA led to approximately 8,400 additional early-stage colorectal cancer diagnoses among seniors between 2011 and 2013.

A 2015 study published in JAMA found that the ACA had increased the number of early-stage cervical cancer diagnoses in women aged 21 to 25.

Early diagnosis doesn’t just increase the likelihood of successful medical intervention; it significantly reduces healthcare costs. When cancer is caught earlier, it is cheaper to treat.

America’s healthcare costs have long been far higher–and our outcomes considerably worse-– than in countries with universal systems. The lobbying clout of Big Pharma and Big Insurance continue to make a cost-effective “Medicare for All” politically impossible, but even with its problems, the ACA has vastly increased the number of Americans who are insured while significantly slowing the rise of healthcare spending; last June, Fortune Magazine reported

The United States will save about $2.6 trillion on health care expenses over a five-year period compared to initial projections made right after the passage of the Affordable Care Act.

While health spending spiked briefly in 2014, evidence shows that it has once again slowed down and will help save Americans trillions between 2014 and 2019, according to a new study by the Urban Institute and Robert Wood Johnson Foundation.

Spending declines will happen across both private health insurance as well as Medicare and Medicaid. Centers for Medicare and Medicaid Services actuaries predicted that total Medicare spending between 2014 and 2019 would be $455 billion lower than the ACA baseline forecast. Projected Medicaid spending over the same time period is expected to be $1.05 billion lower than previous ACA estimates, while private insurance spending projections declined by $664 billion.

I simply do not understand the Republicans’ hysterical opposition to the ACA. Both health outcomes and cost controls have improved, and problems with the program can be fixed with relatively minimal tweaking. The program’s popularity has also improved. (According to survey research, approximately half of those who do remain unhappy with Obamacare complain that it doesn’t go far enough–they would prefer a single-payer system.)

It isn’t just the ACA. Paul Ryan and the GOP are threatening to dismantle both Medicaid and Medicare–programs with low overhead and proven effectiveness– and they are intent on defunding Planned Parenthood, which delivers critical medical services to millions of poor women.

It isn’t as though a free market system could work for healthcare. Market transactions require a willing buyer and a willing seller, both of whom are in possession of all information relevant to the transaction. Equal bargaining power doesn’t describe real-world doctor-patient relationships. In that real world, insurance companies have virtually total control over the options available to those fortunate enough to have coverage.

It seems inconceivable that Ryan, et al, simply do not see the multiple fiscal and social benefits of universal–or at least expanded–access to healthcare. So what accounts for their persistent hostility to programs that have proven their effectiveness? Why are they intent upon substituting block grants for Medicaid, turning Medicare into a “voucher” system, destroying Planned Parenthood and eviscerating the ACA?

If the answer to that question is what I think it is– slashing social programs that benefit millions of Americans will allow them to subsidize the insurance and pharmaceutical industries even more generously and deliver more tax cuts to their wealthy patrons–I wonder how they sleep at night.

If There is a Hell….

Yesterday, I wondered just how venal and despicable our politicians and plutocrats will be allowed to get  before they trigger an inevitable revolt.

Rick Scott, the obscenely rich and demonstrably corrupt Governor of Florida, is evidently trying to push those limits.

The Miami Herald obtained thousands of pages of health department documents under the state’s public records law, including nearly 800 emails and hundreds of memos and reports that detailed the state’s plan to “restructure” CMS. They show that the elimination of children from CMS was the result of a plan to slash spending on sick kids at a time when Florida had a $635.4 million surplus. For the legislative session that begins next month, Gov. Rick Scott has proposed $1 billion in new tax cuts. The spending plan would eliminate an additional 718 health department positions. […]

The parents of one Palm Beach County infant learned on the eve of a critical craniofacial surgery that their 6-month-old son had been “screened out” of CMS. The little boy is profoundly disabled, records show, having been born deaf, without eyes, and with a disfiguring cleft palate. The child’s mother called CMS in preparation for the surgery, only to be told “the screening is showing ‘NO,’ so they would not do anything.”

A post at DailyKos explained the program and summed up the situation:

This program—for Medicaid-qualified children and for those whose parents make too much for Medicaid coverage but not enough for private insurance—provides more intervention with specialists and care devised for kids with special medical needs. Some of the activities of the CMS, like “providing care coordinators to help parents access therapy and medication, and organizing one-stop clinics for kids with sickle cell disease, HIV or cleft palates,” just doesn’t happen with Medicaid.

But there was too much need in the state for the program. It was getting too many enrollees and it became too expensive to treat these kids, so the state had some options. Not having $1 billion in new tax cuts was not among the options. Dropping 9,000 kids was what they settled on.

Rick Scott’s priorities. Excuse me while I take a long shower….