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I need to call out some commenters from my previous thread on the Healthy PA waiver approval.

Rikyrah:

but I thought HHS shoulda just waited until after November.

I think you are wrong for multiple reasons here.  The first, is purely mechanical.  My old team (the insurance plumbers) gamed, over a long database modification weekend, what it would take (from our perspective) to set up a private option style system in our state.  We figured that to do it right (ie actually being able to enroll people, get the docs on board, and pay a claim the first week that we received it), we would want a six month heads-up, and could do it in three or four months with lots of coffee.  Seven weeks from the first day of claims payment eligibility and three weeks to enrollment after the final approval is either impossible or a fiasco in the making.  Proposing a blatantly political stunt means people needlessly are uncovered for an extra month or two.

Secondly, I think this type of stunt is subverting the democratic process.  Our system is designed for political actors to grab a popular chunk of the other guy’s platform/policy, tweak it slightly, relabel it and claim it as their own.  Corbett is engaged in simple politics that he is trying to neutralize his opponent’s popular policy plank by stealing as much of it as he can get away with.  This is normal, mostly rational give and take transactional politics in a high veto point system.  It is healthy.

Finally, Democrats and liberals are the ones who make the argument that government can and should work.  Deliberately making the government not work in an efficient manner is not a good idea.

Patrick:

I don’t think it is such good news. It is not as good as just straight medicaid, and It sets a starting bargaining position for the remaining states who have not yet allowed medicare. In the short run it enrolls more people, in the long run less people at greater expense to them and to the system.

Agreed, in a universe where the Supreme Court did not gut Medicaid expansion, this is distinctly second best.  We are not on that strand of the multiverse. I think your second argument that the Pennsylvania waiver approval weakens federal  bargaining position is a non-sequitor.  The Feds, at this point, are bargaining with states’ political actors who are not too enthused or committed to expansion.  The Feds want to make a deal, the state actors would not mind doing so, but don’t have to.  The party that can more easily walk away has the leverage irregardless without regard to what other parties agree to or not.  The Pennsylvania agreement may set some limits on what non-medical restrictions can be introduced into Medicaid waivers, but that merely limits hold-out states from asking for the moon.  It is minimally relevant for other hold-out states like Wyoming from asking for and getting private option like approval from CMS in the future.

The relevant comparison for Healthy PA is what is the next likely alternative.  Is it straight up Medicaid expansion (which from a plumbing POV should be simple and straightforward), or is it nothing?  In my opinion, no expansion is far more likely than straightforward expansion as the next preferred alternative.  And that will remain the case as long as the Teabaggers control at least one veto point in the state government. They are likely to hold at least one veto point for the rest of this decade.

So again, the question is no coverage for half a million people or pretty decent but sub-optimal coverage for half a million people and the creation of some very powerful stakeholders who will make sure expansion stays in place?  Anyways, Pennsylvania has been a Medicaid managed care state for years now, and the private option/premium support model had already been approved for other states, so it is not much of a precedent.  The shocker would have been full approval without restriction of the original waiver application or full denial, not a deal.

I think the basic question is a moral question that informs our policy judgement — what policy changes are severe enough to justify not covering a quarter million people in year one and half a million people in the out years?  In my opinion, mild inefficiency through skimming and sub-optimal but still pretty good benefit design does not even come close to raising that question.

Playing with lives (Healthy PA edition)Post + Comments (11)