Rational Arguments

OK.  My vacation was fantastic, and now I’m ready to get back into it.  There were lots of questions waiting for me when I returned, so I’m going to devote the next few days to trying to answer some of them.

A number of you don’t fully get Medicaid.  And that’s not surprising, given the lack of truly policy-directed coverage this year.

Basically, Medicaid is supposed to provide health care coverage for the poorest among us.  There are some minimal federal guidelines that are set for Medicaid.  Then, each state gets to implement it as it sees fit.  Some states are more generous, and some less.  Generally, Medicaid is meant to cover those at the low end of the socioeconomic spectrum.  The government defines poor this way:

While you consider the table, remember this amazing fact – a single parent, with a child, who makes minimum wage earns MORE than the poverty level.  That’s how low the line is.

Regardless, Medicaid must cover:

• Kids under 6 years of age to 133% FPL
• Kids 6-18 to 100% FPL
  • SCHIP upps these to 300% FPL in most states
• Pregnant women up to 133% FPL
• Parents to 1996 welfare levels
• The elderly and those with disabilities who receive SSI

Now, states get to implement things above that as they see fit.  But the first important thing to note is that adults without children aren’t mentioned at all.  And in most states, they can’t get Medicaid.

Let me say that again – in most states even the poorest adults without children don’t get Medicaid.

And it gets worse.  Those 1996 welfare levels can be super low.  So low that, for instance, in Alabama a couple with two children making $2500 a year don’t qualify for Medicaid.  Granted, some states are more generous.  But in many, parents have to be insanely poor in order to get Medicaid:

Remember, these are percentages of the table above.  In many states, parents, if they work at all, can’t get Medicaid.

One of the overlooked benefits of health care reform is that it sets guidelines that vastly increase Medicaid coverage nationally.  The federal rules will change such that everyone, even those without children, making 133% FPL (Senate version) or 150% FPL (House version) would get Medicaid.  In some states, that might not be a big deal.  But for those in the states on the left side of the chart, this would result in millions of the poorest among us getting the coverage that many of us already assume they get.

They don’t right now.  And they desperately need it.  And if we fail to pass any reform, they will get nothing.

Ben Nelson has been taking a lot of heat for his last minute deal to secure federal funding to cover Medicaid in his home state of Nebraska.  Turns out he wants to get the same gift for all states:

Senator Ben Nelson, Democrat of Nebraska, has been under fire in recent days over his success in winning some plum provisions for his home state in exchange for his commitment to vote for the Democrats’ big health care legislation. But in a statement on Thursday, Mr. Nelson said he would fight for all states to get the same benefits as Nebraska — a move that some of his Senate colleagues had predicted as inevitable.

I guess he got a “sweetheart” deal.  But come on.  If your “pork” is money to pay for public health insurance for poor people, I really can’t get that upset about it.  His “special interest group” is people making less than 133% of the poverty line?  Yeah, that’s a fearsome lobby.  We better put a stop to them immediately.

I wish more legislators were so “corrupt”.

UPDATE: Austin Frakt points out to me that:

But really what [Nelson's deal] is for is freeing up state money for other things. So, it’s only good for the poor as a side benefit.

I agree that Nelson was getting money for his state, but really – this wasn’t for a company or lobbyist or even the Ben Nelson Bridge.  If you have to get pork for your state, getting it for Medicaid has to be one of the least offensive ways to do it.  I concede it’s unfair that Nebraska gets what other states don’t, but of all the things to come out of health care reform, this isn’t the one that gets me the angriest.

One of the little-noticed gems in the House version of the bill is that one of the way is saves money is by putting more people on Medicaid.  You heard me:

A previous version of the House bill carried an estimated cost of $1.04 trillion over 10 years, but House negotiators were able to lower the price tag in part by expanding Medicaid coverage to a broader slice of the population, the equivalent of all individuals who earn about $16,200 per year. The original House legislation had sought an increase to 133 percent of the federal poverty level, or about $14,400 per year, the same level proposed in the Senate bill.

The adjustment reflects findings by congressional budget analysts that covering the poor through Medicaid — which pays providers far less than Medicare — is far more cost-effective than offering subsidies for private insurance policies, something the bill would provide to middle class individuals who lack access to affordable coverage through their employers.

Medicaid costs less than private insurance.  So it actually costs us as a country less to give people Medicaid than to give people money to buy private insurance.  So…  maybe we’d save even more if we put more people on Medicaid, say up to 250% of the poverty line.  Or… maybe everyone?

And before you start screaming about Medicaid’s low levels of reimbursement, Ezra notes that the bill contains legislation to increase Medicaid’s reimbursements to Medicare levels.

Last night I spoke as part of a panel on health care reform.  The main point I tried to get across was that our health care system is a mess.  It’s the costliest in the world, it gets nowhere near universal coverage, and it is surprisingly disappointing in terms of quality.  This is not news to readers of this blog.  Because it’s so bad, we need real reform.  Massive.  It needs to be big and it needs to be comprehensive.

If you listen to politicians on both sides of the aisle, you’d think we were getting that.  Those on the right claim this is a total government takeover of health care the likes of which have been seen only in their worst socialist nightmares.  Those on the left claim it’s going to revolutionize the system by covering everyone, reducing costs, and realigning the delivery system so that we get quality over quantity.

Not so much.  On either side.

I’m reading over the CBO report for the new and improved Senate Finance Committee bill.  Here’s an actual projection on how the bill will change insurance coverage over the next ten years:

Here’s what I want you to notice.  See the Employer line?  There are currently about 150 million people who have employer based insurance.  This plan will, after a decade, result in a net three million fewer people on employer based insurance.  We will expand Medicaid and SCHIP by 14 million.  We’ll get 23 million people into the insurance exchange.

The number of uninsured will drop 29 million, leaving another 25 million people under the age of 65 still uninsured.

This is socialism? This is comprehensive, massive reform?  Hah! Don’t get me wrong.  This is still a good thing; 29 million fewer uninsured people is better.  I imagine that the tighter regulations will help prevent underinsurance as well.

But let’s not kid ourselves.  A lot of those newly insured are getting coverage from safety net programs.  And the rest are going into the exchange to buy private insurance.  There is no massive government takeover.  Nor, however, is this comprehensive reform.  We will only have reduced uninsurance by about half and will still have more uninsured people than any comparable country.  Or costs will still be massive and rising fast.  And our quality will still likely hover around where it is now.

Yes, this is the most that any administration has ever gotten in terms of health care reform for the country at large.  But is this is really the best we can do?