Congressional Quarterly is outlining some of the new details in the currently hidden health reform bill. There is one idea that sounds like it is an improvement over the first round of leaking but is still a disaester. It concerns grandfathering federal match rates for current Medicaid Expansion beneficiaries.
Sen. Rob Portman, R-Ohio, whose state expanded Medicaid, explained the new idea.
“They’re talking about ways to keep people who are in expanded Medicaid from having the rug pulled out from under them — specifically, not changing the expanded Medicaid over the transition period or even beyond, as long as you’re on Medicaid expansion. If you leave Medicaid expansion and later want to get back on, then you go under normal [matching rates],” he said. “It’s a lot better than what they were talking about initially, from my point of view.”
While many House lawmakers told CQ Roll Call they had concerns about increasing the size of the Medicaid population, they hope that individuals would eventually transition out of the program once they gain employment or purchase coverage on the individual marketplace.
I want to talk about Mary. She is a young woman of prime childbearing age. She works. Her husband is in school and is very healthy. They make 112% of the Federal Poverty Line from her job at Sheetz. They both qualify for Medicaid Expansion in Pennsylvania. She gets pregnant. Her husband picks up some hours at Sheetz as well as they want to put aside some money for the birth. They now make 150% FPL. Her husband is dropped from Medicaid Expansion. She is also dropped from Medicaid Expansion but qualifies for Legacy Medicaid. He buys a Bronze plan for $11 a month out of pocket.
Nine months later, Mary has a happy, healthy baby girl who has an inscrutable smile. The increased family size plus the reduction in hours worked by Mary has dropped family income to 131% FPL. The baby is covered either through Legacy Medicaid or no cost CHIP. Mary and her husband are now Medicaid Expansion eligible again. He loses access to his Exchange subsidy as he has Medicaid coverage eligiblity. They both sign up for Medicaid Expansion again and are told that they only qualify for either a waiting list or greatly reduced benefit package because the match rate has gone from 90% to 55% and the state can’t afford to fund their insurance.
Churn is a fact of life for low income eligibility programs. People have a good stretch at work so they go above guidelines and are either dropped or moved to a different program. People have a bad stretch of work as hours are cut due to seasonality, bad luck or personal situations. Kids are born. People are married. People are divorced. Life happens. Right now, most of these changes would result in a new ID card for health insurance. Under the temporary grandfathering of the federal match rate, the vast majority of the Medicaid Expansion population will become at least temporarily ineligible due to a good stretch and their funding then disappears.
single-payer health care now
(ETA: I know. I know. But I just couldn’t help myself.)
What these folks in congress–for whose health insurance I PAY, damnit–do not seem to understand is just how fucking hard life is at that level of income. And throw some ill health in there (e.g., a chronic condition that folks can’t afford to manage without health insurance), and now they’re too sick to work.
My standard response–rather than single-payer, which, I understand, would be lovely in many ways–is that I want health insurance for myself and my fellow citizens that is as good as the health insurance for members of Congress. Period.
Villago Delenda Est
Average American: “I don’t want health insurance, I want health care!”
GOP: “STFU, taker.”
I have a certain sympathy when unintended consequences arise, even when they’re perverse. It’s the nature of the policy beast, and it’s a lot easier to snipe than to do the actual work to try to help improve people’s lives. But stuff like this, where people trying to do the right thing have punishment baked into the program? It’s galling.
As for Senator Portman and this (italics mine):
Well, that’s the problem, Senator. It’s not about you; it’s about our fellow citizens who don’t have inexpensive, gold or better coverage for life, the way you do. And happen to be poor on top of it.
It is insanity. We went through the same with my daughter. She had health care from her employer but was let go and had to go on something. We used her old salary to get her on the exchange but had to switch to Indiana’s insurance until she got work again 4 months later with benefits. Laid off again but we again used her previous salary to put her on the exchange until she got a job. It had no benefits so she is still on the exchange CareSource. Sucks but it is cheaper than Anthem, by a bunch.
All I could think of was that other people in developed countries don’t have to go through this BULL SHIT and that we suck at health care big time.
Feature, not a bug. They want people who are currently covered to be off Medicaid. They would love to throw them off immediately. What they are afraid of is the political cost of passing a bill that kicks many of their constituents in the teeth right away, since many of those will have voted R and won’t forget who knifed them, come next election. So they want them to be thrown off in six months or a year when local Representative’s fingerprints are no longer on the state of things and it can seem as if it happened by some inevitable natural process. Churn to the rescue!
I have had the experience of being sick while trying to jump through these kinds of hoops. It is the most incredibly debilitating set of experiences; I am at the point where I never want to dial an 800 number again.
And in juggling different plans and income levels on top of that and it’s horrifying.
@Betsy: Single payer could work fine, but there are a number of alternative systems (even the mostly private and largely decentralized, but appropriately regulated, Swiss system that free market fanatics have hyped periodically in a silly attempt at a bait and switch operation) that could solve problems created by this kind of churn. I think commenter PPLCI, above, is correct. Intentionally creating coverage problems because of complicated eligibility rules is probably an intentional move to reduce expenditures and utilization by making access to care difficult.
WRT to that the GOPers in Congress is trying to do, is there a word for genocide against the citizenry of one’s own country? ‘Demogracide’? ‘Citicide’?
@jl: It seems like there ought to be a network of public urgent-care and preventative/wellness clinics that everyone has access to for free or a nominal fee. I feel like making sure that EVERYONE can get a _baseline_ level of medical treatment is the most important thing to do from an ethical standpoint. After having established that, then we worry about how to pay for low-income cancer patients and that sort of thing.
@FlipYrWhig: That’s doable in cities and suburbs, and indeed systems like that exist in blue state (and even some red state) cities. It’s much harder in exurban and rural communities, because of the low population density.
@amygdala: They could have a Medi-Mobile; like a bookmobile.
@amygdala: Share space with the Post Office? Or other county or municipal government services? But, true, I’ve only lived as an adult in NH, NJ, PA, and VA, so I’m probably making assumptions about the landscape.
@WereBear: Telehealth might be a more cost-effective plan. HCW salaries, especially physician, NP, and PA, are high enough that having them, plus necessary support staff, driving around rather than seeing patients, gets pricey.
Problem with telehealth is it requires stable broadband. Usually pretty straightforward in cities and ‘burbs, but more variable beyond that.
@FlipYrWhig: That’s so funny. I mean not really funny. Because what you often hear “housetrained” Republicans saying is, “Only catastrophic coverage should have any public role. Health maintenance coverage, like for sprained fingers and annual well-person visits, should be a personal-responsibility function.”
@FlipYrWhig: They exist: they’re called community health centers, or federally qualified health centers (FQHCs), and you can find them online. FQHCs get a higher Medicaid/Medicare reimbursement rate, and, in return, they must have a sliding fee scale and not turn folks away for lack of ability to pay. Or, I should say “we,” because I work for one. It’s still really, really hard to manage the health care for people whose lives are so close to the edge, who still can’t afford medication (even with jumping through hoops), who have a hard time finding places to go for dental care or for referral care that we can’t provide, etc. We’re actually in pretty good shape, for reasons I”m not comfortable elaborating on here, but the lack of medicaid expansion obviously also affects the finances of CHCs in non-expansion states. We are an expansion state, and we saw the percentage of folks with Medicaid increase from 6% to nearly 20%; that makes a huge difference.
They also have them in rural areas (and sometimes prioritize rural areas), and they also serve what are called special populations, i.e., people who are migrant workers and people who are experiencing homelessness, under separate sections of the legislation.
I just wonder how much “economic development” and “productivity” is impaired by all this bullshiit. How many businesses could get started, and how much job-sorting could occur, if people were able to make rational economic choices, and manage risk, knowing that they have health care coverage no matter what.
I closed my consulting business because I couldn’t be sure what kind of health coverage I could get. Back when I thought Hillary was going to win, I was excited about maybe being able to leave my job and do consulting work again. Now, though — I’m hanging on to a sub-optimal job because even a big raise wouldn’t make the uncertainty worth it. I am middle-aged. I can’t risk being under-covered.
I know many commenters here are in the same boat, or worse, are exposed without adequate coverage now. what could we all accomplish if we just didn’t have to worry about this all the time?
It makes me wonder: Why do we hate America?
@FlipYrWhig: The cleverest thing I’ve seen was a program a friend of a friend runs in rural India–a mobile epilepsy clinic that utilizes the train system to bring the specialists to the patients who need help. They actually use space in the train cars as exam rooms (workable for epilepsy, since the evaluations don’t require specialized equipment). Some of the cars are packed with medications, so that they can be dispensed directly to patients. My friend worked on the train once when she went home to visit family and said it was great to be able to help folks who had never been able to get needed specialty care.
Bob Portman, my Senator, and a walking example of the banality of evil.
“It’s a lot better than they were talking about.” It’s not better than the present set-up.
Making a note of this to include in my next missive to him. Thanks for the info, David.
sheila in nc
Yes! Your tax dollars at work. Funded through the Health Resources & Services Administration, part of the Department of Health and Human Services.
@WereBear: And there are a lot of old people struggling with it, too. My father was lost in voice-mail hell many a time.
Dave, any chance you could devote a post to ripping Mr. Ponnuru a new one?
David, this is a perfect post for the Tumblr mentioned here a few months ago – Could Happen To You.
Reactionary free market fanatics see any kind of guarantee of a minimum level of health care to all as merely more welfare for the poor and undeserving. In particular, there seems to be a mindless attack on the very idea of comprehensive health insurance. They sound plausible if you read the first page of on Econ 101 explanation of how insurance works, but all the attack points I know about are wrong.
Some examples are. The probability of a health expenditure is one sooner or later so not really insurable risk (but, life insurance). Preventive care should be and individual responsibility, and have noting to do with an insurance policy (but, pretty much any commercial fire insurance policy, going back over 200 years). The actuarial value of many claims cannot be objectively observed or set by market prices, so no really a standard insurance policy (OK, pretty much any insurance policy that includes provision of legal representation, as is common in auto insurance). Appropriate regulation to ensure a stable market is ‘big government interference’. But any stable insurance market is heavily regulated. The UK and US was far less ideological about this for other lines of insurance from the late 18th through early 20th centuries than they are now.
I’m not really sure what these nutcases think they are trying to accomplish. What big money interests have a stake in drastically shrinking the ability of regular people to pay for medical care. Big pharma and medical equipment companies? Where is their research money and slush funds for hookers and blow going to come from? Can’t be insurance industry itself, can it? Maybe AMA? (IMHO, they have their heads for far up their asses, could be them. They are still trying to delude themselves into thinking that they are still influential and wealthy ‘players’, rather than very skilled help). Is it purely butt ignorant and stupid ideology? Or do they see it as part of the race/ethnicity wedge issue? Maybe large hospital chains and medical groups would benefit?
I dunno. Anyone know what is behind this madness, or have a good guess?
For anyone who needs a health center (or knows someone who does):
I have lost track of how many times a clueless person with health care smugly informs me they don’t understand the big fuss because “there are charities for that” or “I’m sure there are programs” or the classic “they can just go to the emergency room, they don’t even pay.” And then they chuckle indulgently at me because I’m being so childishly emotional or something.
The last thing someone with a serious diagnosis needs is sitting on the phone waiting to hear if the insurance company allows the next stage in their treatment. The only thing worse is not having insurance, and trying to track down something or someone that might help with part of their new challenges, much less the giant maze, on fire, they now have to navigate.
I know people who have done it, and have told me, in all seriousness. “I didn’t know what I was getting involved in. If it happens again, I’ll just die.”
But I despair of coming up with an “elevator pitch” that encapsulates this for the clueless.
@jl: It’s simply madness.
They see all these other people sucking up scarce resources they wish to have reserved for them.
To stupid to understand that a healthy populace makes them healthier. No, they are all scrooging out on “let them die and decrease the surplus population.”
It makes them feel important. It’s shocking and disgusting how many such “moral” stances boil down to a toddler mind in an adult body.
@jl: Calvinistic predestination theology at work. We have a very strong attitude of “You must have been so bad, to deserve such misfortune” in this society.
I think it comes partly from our early English Puritan and Scots Calvinist influences — now secularized as part of a more victim-blaming, priggish societal culture.
And partly from our “classless society” national mythology, wherein the idea is that merit always is supposed to rise to the top. Without an aristocracy to be trained to look up to, Americans early on substituted rich people. Achievement is supposedly a hallmark of the elect.
All in all, if something horrible happens to you, you must have been a bad boy.
It’s nice though, because there’s a valuable corollary: “If something bad happens to ME, it can’t be because I’m bad! I work hard! Oh, it’s because [some other group that needs to be singled out and readied for oppression] took something away from me!”
@WereBear: Tell them that there are such things as ‘standard of care’ the knowledgeable professionals agree on, and there is a thing called ‘continuity of care’, which means that the ‘standard of care’ is delivered in a timely way. And if continuity of appropriate standard of care is not delivered, people get sicker, they fall down and can’t get up. And stuff costs more to fix. Sooner or later things get serious enough so that there are state and federal laws saying that someone has to fix bad health stuff. Maybe they will understand that.
A national health insurance system that gave everyone a standard minimum health insurance policy, that did away with Medicaid, and Medicare and the metal dog’s breakfast of exchange plans, and different employer plans would provide better care for everyone at lower average cost. it could be done with single payer, private system with budget caps, highly regulated mostly private decentralized market system. If people want more coverage they could get it on a supplemental insurance market, as they do now in many industrialized high income countries.
@Betsy: Really good points. It makes sense to allow people like yourself to follow an entrepreneurial route. You get to provide services and do the work you enjoy. And the job you leave behind provides an opening for someone in need of work. I hope this country will one day (perhaps after the Trumpocalypse) provide healthcare to everyone in a system that can’t be f*cked up by a craven political party so you can do your consulting work again.
@jl: That’s all good, accurate, stuff.
Problem is, they don’t believe it.
Sigh. We must work on people we can persuade. The clueless wouldn’t get a clue if I duct-taped it to their face.
@narya: I knew that, and yet I still posted what I posted… I suppose my point is that it would be nice if virtually everyone everywhere used the public system first, because that way it would never be stigmatized as welfare, and you would never be unsure where to go. (I have what I think is pretty good health insurance, but the process of just finding a freakin’ doctor for nothing in particular is maddening. Like what the hell is “internal medicine”? Isn’t almost all medicine about the inside of the body?). But I have no idea what would be involved in changing the culture that way.
@david Anderson This is just an extraordinary and understandable explanation of a complicated and bad scheme! Thank you. The Republicans who thought this up are just so warped.
Mary and her husband should just cash in a few municipal bonds. That ought to tide them over until hubby gets his own hedge fund seed money.
Keep It Simple and Take Credit
By Jack Meserve from February 3, 2017, 5:42 pm
@FlipYrWhig: Internal medicine is to adults as pediatrics is to children.
I agree, it is a misleading name for a generalist.
I’ve had the same internist for fifteen years. She has seen me through several serious diagnoses (even if the main thing she did was send me to a specialist), and I dread the day she retires. It’s good to have someone in your corner and a chore to break a new doctor in.