Medicaid is going to be a big area of debate, so let’s go over the mechanics of Medicaid in any state. I will be speaking at a very high level and without too much state specific detail. This is not a state specific guide-book to Medicaid. It is just a reference guide to build a light framework.
What is Medicaid
Medicaid is a federal-state partnership program that originated in 1965 to pay for health care and long term care for people who can not afford it. Eligibility has expanded significantly over time. The program varies significantly by state.
Who gets covered
There are several major groups that are eligible to receive coverage. Each state has to meet minimum baselines and can elect to change eligibility criteria to expand coverage to certain groups. But let’s break it down now:
- Old people in nursing homes
- Sick to very sick people
- Poor kids
- Poor pregnant women
- Working poor adults (Medicaid Expansion in the ACA)
These are massive overgeneralizations and are a bit flippant. Eligibility varies by state. Some states like Massachusetts would cover childless adults up to or over the federal poverty line even before the ACA passed. Other states like Florida won’t cover non-chronically ill childless adults at any income level.
Who pays for Medicaid
We all do. Medicaid is a federal-state partnership. For non-expansion groups, the Feds pay between one and three dollars for every dollar a state spends. For Expansion the feds under current law as of Monday morning pay nineteen dollars for every dollar the state spends, this will decrease to nine federal dollars for every state dollar. It is usually paid for out of general revenue instead of a dedicated tax like Medicare or Social Security.
What are the benefits
Medicaid is comprehensive health insurance. It covers the typical hospital, doctor, prescription, rehab charges. It also will cover some dental and vision services. Additionally, Medicaid tends to be one of the biggest payers for mental and behavioral health services in the country. Since Medicaid also acts as a long term care supplement, it will spend a lot of money on nursing homes and long term home care.
How is care paid for
There are two primary methods of paying for care. In some states, there is a fee for service component where the state (or a contractor for the state) processes claims and acts as a pass through entity for federal money. This is becoming less common. The more common method is some type of Medicaid Managed Care Organization (MCO) which is an HMO for Medicaid. Here the state gives the MCO a fixed sum of money every month to cover the expenses of its members. Each state will do things differently. Some states are 100% MCO with a sole source MCO covering all benefits. Other states will split physical health, behavioral health and long term care into separate MCO contracts. Other states will have a hybrid fee for service and MCO model. It varies. [DISCLAIMER— I used to work as a data analyst for a Medicaid Managed Care Organization, UPMC Health Plan — I don’t think the MCO model is intrinsically evil ]
Do I know someone on Medicaid?
I would be shocked if you did not.
Who should I talk to about nursing home assistance
Give the wonderful people at your local Area Agency on Aging (AAA) a call. They know this stuff cold and they know your state laws way better than someone on the internet ever will.
If I’m not old, how do I apply
There are a lot of pathways. The first is to go on Healthcare.gov or your state exchange and apply. Currently there is a “no wrong door” process where the exchanges will forward your information onto the state Medicaid program if you look like you qualify. If you don’t want to deal with that, contact the local county assistance office. If you can’t find that, call the local hospital and ask to speak to a social worker. They might not be able to get you started but they will be able to tell you where to go to get started.
prob50
Nice little primer on the subject.
Rhonda
FWIW, I think a poor working age person must have a child or be pregnant to qualify.
Phylllis
I used to be a Medicaid caseworker here in South Carolina. My caseload consisted of about 98% working single or two-parent households who either had jobs that offered no health insurance, or if their jobs did have insurance, the family premium would eat up almost all of their take home pay. I remember a city council member being shocked to learn city employees had their kids on Medicaid and the reason why–he had no idea their family premium was in the $400-$500 a month range.
For the 1-2% who weren’t working, they were either disabled, or could not find work locally & couldn’t make traveling the average 30-miles one way to nearby communities with jobs work regarding child care, etc.
rikyrah
thanks for the primer
rikyrah
just a reminder…
THIS is who takes the largest % of Medicaid Dollars.
Robert and Emily’s Grandma and Grandpa SHOULD be the poster children for Medicaid.
In terms of Medicaid $$$$, the other groups are pikers compared to this one.
raven
John Oliver on the shit.
PaulW
My father worked as a legal guardian for decades.
One of the biggest steps a guardian had to do for persons placed under guardianship – due to their elder status, their poverty, level of mental incapacity – was to get them onto Medicaid care. Considering they would have died quicker and in suffering, this was a necessity.
A lot of nursing homes, hospices, and assisted living facilities rely on Medicaid funding to keep their wards and residents at a modicum of comfort. If that money goes away… I’ve seen reports that if it happens in Ohio they are going to close one out of four nursing homes. If it happens in FLORIDA I worry most of them will close.
To anyone on the Far Right who thinks Medicaid is barely used, or is a source of fraud, go screw yourselves. Medicaid is a goddamn lifeline for millions. WHAT THE HELL IS WRONG WITH YOU TAX-CUTTING GREEDHEADS?
Phylllis
@rikyrah: Let me tell you about the number of well-to-do families who were incensed they couldn’t get nursing home Medicaid, because, as they put it, “why should mom have to spend all her money to be taken care of?”
dr. bloor
@Phylllis: Shuffling money to get it out of mom and dad’s name in time is a cottage industry in some places.
Phylllis
@dr. bloor: Absolutely. We even used to counsel people to go ahead and make the transfer and take the penalty (depending on their situation), because it would cost them less in the long run. Other folks, we’d keep that part to ourselves. Because they were a**holes.
JeanneT
I hold the financial power of attorney for my MIL, and help her with her accounts and cover her expenses when she’s short. In February I sent my inlaws my annual note about their mother’s finances – she’s 90 and currently living in a senior living apartment, receiving $300/mo rent support from the government. If she should need to go into long term care, or get in home care, she will be totally dependent on Medicaid: she has no resources to fall back on besides Social Security and two tiny pensions.
So I pointed out to her children that with the Repubs in charge of Congress and the presidency, it is very likely that her rent assistance and her options for long term care will be reduced or eliminated. And that Medicare could also be at risk.
My SIL was incensed that I should bring up politics in financial planning for MIL, and that of course the Congress will not mess with those programs: they have voters who use them. She also said she can’t possibly help w/her mom’s finances, since she is relying on Social Security and Medicare herself and barely has enough to get by. So she’s at risk, too, but denying it.
Yarrow
@rikyrah: And let us not forget the filial responsibility laws. If Robert’s and Emily’s grandmother gets kicked off Medicaid, Robert and Emily’s mother Susan will be bringing grandma back to live with all of them in their home. Because IT”S THE LAW. They can thank the “Party of Personal Responsibility” for that.
WereBear
Are these the same people who tell the rest of us we just should have made more money in our lives?
Yeah, I know :)
Ohio Mom
@dr. bloor: It is a little screwy that Grandma or Grandpa could spend all their money on wine, women/men and song, and then be broke enough for a Medicaid nursing home, but if they want to give money to their children and grandchildren after the look-back period, that’s a no-no.
I understand the logic of why this is so but if we weren’t such a miserly country we would probably allow ourselves a different logic.
In the end, the well-to-do have ways of sheltering their assets, and those with less are prevented from passing anything down. It just reinforces inequality.
laura
@PaulW: Getting my mom on Medicaid was the most bureaucratically difficult thing I’ve ever done. As part of the conservatorship, the court directed almost all of her ss and pension to my dad to maintain the “community”. She received a level of care and comfort that was well beyond our abilities -and for which I will forever be grateful. Until she died, my biggest fear was that dad would die first-and he almost did. With no where to transfer funds, she would have been disqualified and disenrolled in Medicaid and unable to meet the cost of care and no suitable place to go.
When dad dies, Medicaid/California will claw back every penny in the estate. They’re welcome to it.
My worst fears are about to become the reality for so many people and they have no idea it’s coming and will, of course likely blame any/everyone but themselves.
Eric U.
@Yarrow: that does it, my brother is never moving to Pennsylvania. Of course, I live in the state with the stupidest history of enforcing filial support laws
@Ohio Mom: getting my brother on Medicaid was very difficult. I don’t know why the people that can help are so inclined to lie about it, but it happened at every chance. Finally had to get adult protective services involved, and they pushed things through.
Lee
Yep. My dad moved everything out of his mom’s name so she would qualify for medicaid.
He already has me as co-owner on many things so to make the transition easier from him to me.
WereBear
And part of this is also a crisis in health care; though unacknowledged.
We’ve gotten really really good at simply keeping people alive. Yet I think we neglect strategies that will help people not reach that terrible point where they are in a nursing home for years and years, without having any kind of good time. We are not paying enough attention to how people slide into this twilight and then linger there; someone who, in their better health years, would have been horrified at how they are living now.
I’m not trying to be cruel or unfeeling. I happen to come from a family with strong quality of life traditions. And certainly I’m not talking about someone with a challenge which can be overcome with good care.
But this became a stark reality for me when my Catholic stepmother made all the decisions for my dementia-challenged father. We had no real recourse when she kept demanding treatments and interventions that were prompted by her religious convictions; they were certainly not what my father would have wanted.
In the end she let him go, but it sucked up a lot of family and government money; for absolutely negative results.
Whew! Just had to get that off my chest.
It’s a twisted situation we are in now; the right wing are the first to scream about death panels and oppose Right to Die, yet will not lift a finger to help the people they push into that situation.
David Anderson
@Rhonda: It depends on the state. Mississippi has very different rules than Massachusetts. And that is even before we take into account Medicaid Expansion.
laura
@WereBear: I get it WearBear! Mom would have been mortified if she was cognizant, but dementia stripped away all of that. I’m grateful to have had total support by dad and my brothers to make all the decisions about mom’s care. She and I were very close and because we were close, I knew what she wanted.
Decision making was easy and based on very simple principles -will it maximize joy or minimize suffering.
I’m sorry that your stepmother made decisions based upon religious dogma. It must have had the effect of maximizing suffering to the benefit of no one.
Eric U.
@WereBear:
my mother in law is not being kept alive by the government, and I’m sure she would never have considered a DNR anyway, but she is almost totally gone mentally. She was obsessed over her health, and it seems to have worked. The one thing you don’t seem to be able to control is dementia. I really don’t want to be like that for very long. My father suffered from dementia for the last 5 years of his life, although it was really bad for only the last 2. It’s really tough to deal with because the alternative seems like actively working to let them die. My dad’s personality totally changed, and he was horrible to a lot of people those last 2 years. It’s a really bad way to remember someone.
Ohio Mom
I know Medicaid varies widely among the states — that is one reason why the Republicans’ insistence that block-granting Medicaid will give states the ability to closely monitor and administer the program is such utter BS. They already have those abilities and responsibilities.
But don’t most states also use Medicaid to support adults with disabilities? As I’ve noted before, a year in a group homes costs $30,000-40,000 in my area, and it is Medicaid that pays for it.
For me, as a mom of a kid with autism, this aspect of Medicaid is BIG. Can you address this, David?
So often, adults with disabilities get overlooked.
rikyrah
@JeanneT:
Have you emailed her about the basics of Trumpcare?
rikyrah
@Yarrow:
It’s up to you folks with Trumpettes in the family to remind them of this, and with a deadpan voice tell them.
” I guess this is all part of making America great again.”
WereBear
On the other hand, we have our helpless elders being regarded as a cash cow by the medical profession.
For years, my father was on expensive drugs with side effects which led to more expensive drugs. If he hadn’t demanded that none of us allow another bypass operation, my stepmother would have allowed the doctors who were pushing for it — and the last one cost half a million because he was diabetic. Interventions like catheterization led to constant antibiotics; it wasn’t until we got to the feeding tube that she stopped.
None of it was life enhancing. In fact, it was undermining what little quality of life he had.
I was fine with putting him into a nursing home because he could not be cared for in a home situation. He was a danger to himself and others. And the first time he got pneumonia because he could no longer chew and swallow properly, my family would have let him go with pain relief.
I still think that would have been a better way to handle it.
David Anderson
@Ohio Mom: will reply this pm
WereBear
So true! And these are the very people for whom an assisted living situation, or an environment that is wheelchair friendly, or any number of things, can give them a happy and fulfilling life.
Yet a ton more money is poured into keeping people barely aware — and greatly suffering from it — alive.
The blissful Alzheimer’s patient is a very rare instance; because people are distressed and anxious and have no way of soothing that. They have “pain in their brain” and we can’t help that.
I think perpetuating such a situation is cruel.
ArchTeryx
I’m an example of someone for whom Medicaid is literally keeping me alive. I’d never dreamed I’d end up on it, but after my last science-related job laid me off (it was a temp job, of course, like every other one I’ve ever worked) I quickly ran through unemployment.
At that point it was: Move to a state that didn’t refuse the Medicaid expansion, or die. Even my mother, who I was living with at the time and got along with famously, pushed me to move out of her state.
And in a truly great stroke of luck, my closest friend had a spare bedroom he was willing to give to me, in New York State. NYS was an expansion state.
It took 6 months of warring with the NY State of Health people to get onto it. They kept demanding I prove a negative – that I had no income. How exactly do you prove that? Write a nice note saying “I have no income?”. After several months of back and forth, they finally agreed to accept my unemployment termination letter, my job termination letter, and my residency proof as sufficient, and I got onto Medicaid.
The SINGLE biggest thing that Medicaid Expansion corrected was to eliminate “demographic exclusions”. In many states, as a single person with no children, I couldn’t get on Medicaid even with zero income. I was simply deemed expendable and told to go off and die quietly. The ACA attempted to correct that. John Roberts sabotaged it in many states. But even with that, the #1 source of the decrease in the uninsured was the elimination of demographc exclusions. Now ANYONE could get on Medicaid if their income was below a certain level, no matter what. Combine that with the fact that once on, you were eligible for a YEAR (i.e., no more month to month income tests) and asset tests were eliminated (you could actually own a car that wasn’t falling to pieces) and Medicaid actually started working as intended.
And after all that, now ZEGS wants to take it all away from folks like me, and return us to “go off somewhere and die quietly”.
Ruckus
@PaulW:
Probably worse than you make it sound. How much taxes does anyone pay for Medicaid? Not all that much as a percentage, I’d bet. They wouldn’t even notice the difference. Of course the assholes want to end the whole thing so that they can be openly racist and cheap bastards.
ArchTeryx
@Ruckus: And none of them realize that in sticking it to POC, they also, in many cases, will be sticking it to themselves just as hard. And to folks like me – white guys with STEM degrees that can’t find work outside of adjunct faculty positions – but to these racist crackers, that’s a feature, not a bug. They consider eggheads like me expendable at best and race traitors at worst, because I won’t join them in their little RaHoWa fantasy cosplays.
Ohio Mom
@David Anderson:
Thanks! I’m busy booked this afternoon but I will make sure I look for it.
I only know the little I know because I have pieced bits together. None of the local disability organizations ever addresses this.
We have a pretty regular calendar of conferences and workshops in the Cincinnati area on DD issues. Often they include a session on how and why you should apply for Medicaid and SSI, but they never talk about how these programs came to be, how they are funded, why they are so underfunded, and what challenges they face.
I think the conference organizers are afraid to be “political” but we wouldn’t have IDEA or the ADA or anything else that recognizes the rights of our disabled loved ones if no one before us had been afraid to “get political.”
At the annual local Empowering Families conference at the beginning of this month, the organizers told me they weren’t bringing up the threat of Medicaid being block-granted because the conference is heavily attended by parents of younger kids just starting out and “we don’t want to scare them.”
The organizers are getting tired of me badgering them but not as tired as I am of them.
Ohio Mom
I typo-ed my email address again and as a result, am in moderation.
ArchTeryx
@Rhonda: That USED to be the way it was, before the ACA did away with demographic exclusions. In the Medicaid expansion refusenik states, it’s still true. In the ones that took the expansion, it was categorically eliminated – the ACA does not allow demographic or asset-based exclusions in Medicaid. Your income is the only qualifier, and they only test income once a year.
(This is not to say that state exchanges don’t play games with income documentation – my battles with NY State of Health are legendary, because I am self-employed and my income varies wildly from year to year. Eventually, though, we finally got on the same page, and now my Medicaid qualification from year to year is mostly a formality).
prob50
@WereBear:
My uncle Hy had Alzheimer’s and would go back to his time as an infantryman in WWII much of the time. Horrible enough, because he was at the front and saw a lot, but when he was actually somewhat lucid he realized what was happening to him and he would just cry.
WereBear
@ArchTeryx: Which is a much better way of handling it.
There aren’t any jobs. Especially for a sick person.
Nixon! Even a well-employed person is totally screwed if they get sick enough. Then they lose their job and their health insurance, just when they need it the most.
randy khan
Interesting note from the Capitol Forum, which covers a range of legislative and regulatory issues in D.C. (I won’t vouch for the accuracy of its predictions, but its analysis on issues I care about generally is pretty good.) This was part of a broader piece setting or updating odds on various potential Administration-related items, the most worrisome was keeping the odds of a trade war above 50%. Anyway, here’s what it had to say about RyanCare/TrumpCare:
“We are lowering our outlook for Obamacare repeal and replace to 40% chance of passing from the “less than 50%” that we have predicted previously. Our thesis is simple—Republicans will prove less willing to risk their majorities in Congress to pass complex, unpopular healthcare legislation than Democrats proved to be in 2010.”
I have to say that the last sentence nicely encapsulates one particular characteristic of both parties.
Steeplejack
@Ohio Mom:
Doesn’t your browser maintain your nym and e-mail address? Mine do, on computer, tablet and phone.
But maybe you are commenting from a public computer/device or one you share with someone else?
WereBear
@prob50: I know. I saw my husband’s grandfather, an avid outdoorsman, wind up in a wheelchair parked by a window; constantly in distress, unable to eat anything that hadn’t been run through a blender; and he was one of the better off ones.
There were people there who spent all day restrained in their wheelchairs screaming and wetting themselves. Any rational person would question why these people were still being constantly treated as though they could get well.
prob50
@Ruckus:
On wage earnings approximately 1.45%.
WereBear
@prob50: And why can’t I say “I want to keep this working as it should”?
You ask me, not everyone is sick and going to feel the cold breath of not having healthcare for it. But far more have elderly relatives who need that care. That is what might hit them between the eyes.
japa21
Price already has his arguments set for when the CBO releases its numbers, specially if the numbers show a large number of people losing coverage. He will point out the CBO is notorious for overestimating things and will use as his prime example how they overestimated the number of people who would end up covered by Obamacare. Of course, the CBO’s estimation was based on the Medicaid expansion being nationwide. If those states that refused the expansion had gone along with it, the CBO’s estimate probably would have been lower than the actual number.
It is highly doubtful that anybody in the press will call him out on this.
Mingobat f/k/a Karen in GA
@PaulW: My father-in-law with dementia is in a nursing home paid for by Medicaid. It devastated my husband and his brother to acknowledge that their dad had deteriorated to the point where he needed to go there. My husband’s relatives keep saying, their voices dripping with concern, “How is your father? How’s your mom holding up? I know it must be so hard on you and your brother to see him like that, but you’re making sure he’s okay and he’s got people around him who know how to help him,” blah blah blah.
Then those fuckers voted for Trump. They post their racist bullshit pro-Trump memes on Facebook, and I point out that Republicans want to gut Medicaid and without it we can’t care for my father-in-law. What will we do then?
Their response: [crickets]
Did I call them fuckers yet?
lgerard
To all those who battled through the Medicaid certification process
One of the changes trumpcare would bring is more frequent re-certification…..at least every 6 months
ArchTeryx
@lgerard: That’s the LEAST of what Trumpcare would do to Medicaid. It basically phases out expansion, block-grants whatever of Medicaid remains, and guarantees the return of demographic exclusions, asset tests and all the rest of the horror show Medicaid used to be. They want it reduced to such a rump it covers almost nobody, just like before.
WereBear
@Mingobat f/k/a Karen in GA: Yes. It is infuriating.
Ohio Mom
@Steeplejack: It probably has to do with me not understanding my phone and not setting something up the correct way — the laptop automatically remembers, the phone doesn’t.
And I am a sloppy typist, especially on the tiny phone keyboard.
Chris
@Rhonda:
It depends on the state. In Florida, which refused the expansion, any person must have a child to qualify – even if your income is an absolute zero, they still wash their hands of you. In Maryland, which I moved back to as soon as I finished my degree in Florida, it’s not that way – nonexistent or extremely low income is enough to qualify, and even after you’re no longer eligible for Medicaid you still get partial subsidization of your health plans up to a certain income level.
Chris
@ArchTeryx:
In Maryland, yes. IIRC, that’s pretty much literally all I had to do to get on Medicaid. Ugh. I thought NY would have enough blue in it to avoid all that kind of horsecrap.
JeanneT
@rikyrah: Have I sent her more info? No, I haven’t been able to think of a way to give her good info without setting off her anger and defensiveness. Articles and analysis that seem calm and reasoned to me seem like left wing slander and conspiracies to her. But I did tell her I would be working as hard as I can to protect her and her mom from the attacks on Social Security, Medicare and Medicaid. She did not thank me!
Xantar
I work for Maryland Medicaid (hi Chris!), and you should see the worksheet we use for determining eligibility for programs. The way it works in Maryland is there are different coverage groups each with different eligibility standards and covered services. There’s one called L98 which covers nursing home care. S02 is for people with SSI. S98 is for people with serious medical illnesses. P02 is for pregnant women.
Medicaid Expansion technically didn’t expand eligibility for any of these coverage groups. It instead created another group: A02 which covers adults age 18-65 with incomes up to 138% of the Federal Poverty Line.
I’m glad that I work in an Expansion state, but this system is still crazy and unnecessarily complicated. Ask any government worker and they will tell you that we could save a lot of administrative costs by lumping everybody into one simply coverage group. Instead, we have so many groups that listing them all literally covers an entire page. Unfortunately, our coverage groups are dictated by federal and state statutes, so we can’t simplify them until legislators put their mind to it.
But then again, we do have Medicaid Expansion, and if I have to deal with a kludgy and complex eligibility process to have it, that’s a tradeoff I’ll take.
TriassicSands
David, that’s a very good Medicaid 101. There are a lot of misconceptions about Medicaid and without going into great detail you’ve at least alluded to a lot of areas that cause confusion. In my experience the biggest misconception (before the ACA) was that poor people could get Medicaid. As you point out, in a state like Mississippi an adult male couldn’t get Medicaid no matter how poor he was. For other people the income limit was preposterous — I think I read at one point that if you made more than $3000 a year you were ineligible.
Nice job. Now, if only we could get Americans in general to read and understand stuff like this.
Chris
@Xantar:
Hi back! Thanks for your good work on behalf of the people of Maryland.
And from a customer point of view, the subsidized marketplace is a kafkaesque freaking disaster in terms of getting any problems with your account (and they inevitably happen) cleared out. Different, but related, problem.
But yes. Having had a bunch of medical problems in Florida that had me dealing with the insurance companies with no assistance of this kind, I still much prefer this.
Chris
@TriassicSands:
Yes.
That was a rude awakening in Florida (and I suspect a lot of people are still under the misconception that since the ACA, people can surely get on Medicaid now, when the reality is that even that’s only in some states). I expected the safety net to be miserly as hell, to be dystopianly bureaucratized, to have to answer a zillion different questions and jump through a zillion different hoops to prove that I had no income, and I expected that I’d lose it the second I was bringing in so much as a dollar a week in income. I didn’t expect it to be completely nonexistent even for people with absolutely no money, which was the reality in no-Medicaid-expansion Florida.
Most of us really have no idea just how freaking bad the options are for poor people in America until we’ve actually lived it, or had a brush with it.
Stan
A huge percentage (I’ve seen estimates of two-thirds to three-quarters) of Medicaid payout goes to support the elderly. Which makes sense…. its where most health spending happens.
By the way….WHY AREN’T WE JUST PUTTING EVERYONE ON MEDICAID?
We already know how it works. We already have the bureaucracy in place. This would be a lead-pipe cinch.
David Anderson
@Stan: Doctors would scream as that is a massive pay cut. Upper income individuals with good private insurance would scream as the government would be in position to say NO to their desires.
amygdala
@Stan:
David is right, that the low reimbursement rates (in some states) are an issue. They lead to access problems for some kinds of specialty care, especially so-called cognitive specialties where high volume isn’t feasible or ethical.
Some, like HIV medicine or pediatric specialties, have supplementary programs to fill the gap. But in my specialty (neurology), in California where Medicaid (Medi-Cal) pays something like 20% of charges, it is extremely difficult to find a private practice neurologist that will see these patients in the office. I knew private docs who didn’t bother billing inpatient charges. It wasn’t worth the effort.
We took care of these patients in our clinic, which was in a safety net hospital. With trainees, whose salaries are lowers than NPs and PAs, and systems experienced in dealing with Medi-Cal’s many, many rules and restrictions, it wasn’t as much of a a money-loser as it is for private practitioners. But I always knew when there was a new reviewer in Sacramento. An expensive seizure drug that a patient had been on for years, that we had unassailable evidence was the only one that worked, suddenly were not getting approved. And you hoped like hell you could get someone on the line to reverse the decision before the patient had a seizure, lost their drivers license (again), and went down that rabbit hole.
And that’s in a city with a public hospital. For patients in the exurbs or rural communities, or even in red county cities that don’t fund public hospitals… they have few options. There are UC hospitals–teaching hospitals of public medical schools–that don’t take Medi-Cal in their specialty clinics. Not kidding.
It’s easy to slag the private practitioners, but it’s a vicious cycle for them. They lose money on every Medi-Cal patient they see. If you get a rep for seeing them, they rapidly become the bulk of the practice, and the numbers don’t add up.
As mentioned, it varies by state. A neurosurgeon friend left for the midwest some years ago and was amazed that Wisconsin Medicaid paid nearly what Medicare did. Probably not any more, but he was surprised.
The state involvement creates another problem that doesn’t get much attention. In bad budget years, the state looks to boot people off Medicaid. So in addition to interstate variability regarding eligibility and benefits, there’s intrastate variability year by year. It’s a nightmare for patients, because what isn’t variable is how much more vulnerable they are when budgets are tight. Same thing happens, although usually to a lesser extent, with the VA.
The reasoning, such as it is, is that if you shut clinics and get rid of hospital beds, people will stop needing them. If there’s excess capacity, sure. But that’s not the case in public hospitals, and the cuts have gone from fat to muscle to bone to hemicorporectomy.
artem1s
so we’ve been hearing a lot of numbers on who has gotten health care under ACA and who stands to lose it under Trumpcare. One set of stats I’d be interested to know more about is how have the bankruptcies due to medical bills shifted in the last 8 years? If my memory serves me, this discussion of affordability began decades ago because we were seeing more and more people going into an economic spiral. The combo of rising health care costs, rising insurance rates, coverage caps, and denial of coverage was bankrupting more and more people. And then W’s tanking the economy meant millions who couldn’t pay for health care, mortgages or basic needs because their retirement was gone and millions lost their jobs.
I’d really like to know if anyone has done any research on how ACA has impacted bankruptcy rates and how that has impacted the larger economy. My personal nightmare is a W level economic disaster, followed by massive layoffs. I spent 18 months under and unemployed because of the 2001 stock market crash and the housing bubble that burst here in the rust belt in 2004/05. I eventually got a better job but it took me 10 years to recover savings and pay down resulting debt from that mess. And I didn’t come anywhere near losing my house. The GOP is overlooking this aspect of another failed health care experiment. And this time there won’t be anyone in Congress or the WH who understands (or cares about) what has to be done to fix it.
Stan
@David Anderson:
I’m OK with those features.
And if reimbursement rates are too low (we can argue fro a long time what that means) they can be tweaked. It’s not a fatal problem.
amygdala
@artem1s: There has been some research on this. If it’s true that bending the cost curve is the ultimate answer, it only makes the potential impending demise of the ACA harder to take. That elusive goal was finally starting to happen.
I’m sorry you’ve been through such hell. Congress is pretty much insulated from what happened to so much of the public in 2008, and therein lies a big part of the problem.
David Anderson
@Stan: I’m not opposed to those outcomes either. But that is why assembling a coalition of 218-51-1-5 is tough much less than 218-60-1-5 for those outcomes is damn near impossible.
Another Scott
@TriassicSands: My mom was on Medicaid her last few years in a nursing home. In addition to the well-known income issues and clawbacks and all the rest that middle-class and above families have to think about, there’s another (I think) little appreciated aspect of Medicaid and nursing homes:
The nursing home basically takes their Social Security check and gives them $10-15/week in exchange.
One can argue that that makes sense, but I don’t think people really think about it too much until the D-Day arrives. I’d guess most people think that “Hey, she paid into Medicaid for decades, her taxes will take care of it”, but it doesn’t work that way. At that point, considering what it means with respect to keeping them in a lifestyle even a tiny fraction like what they previously had, can be very painful…
Medicaid isn’t always “free” by any stretch of the imagination. It’s a last-result way to keep vulnerable people who have no other options warm, and safe, and mostly healthy (but much more can and should be done to do better). The GOP painting it as a grand, over-the-top benefit for moochers and losers is infuriating.
Hang in there! Donnie and Paulie and the rest aren’t going to win on this.
Cheers,
Scott.