How About A Medicaid Buy-In?

While something called "health care reform" will be passed, it's pretty clear now that there will be no real reform in the bill. If there is good remaining in the bill, it will be Medicaid expansion and subsidies for less well off person to purchase minimal insurance.

How can you get the good in this bill and still have a chance for health care reform in the future? The mandates are a sticking point of course. They are the lever for the political bargaining that might make health care reform possible in the future. But there are others. Ben Nelson is not done yet and Bart Stupak is still waiting in the House. The problem with the subsidies is that they are going to be channelled through exchanges which will be subject to a Stupak Amendment. The current bill makes that too bitter a pill to swallow I think.

There is a solution to these problems I think. Instead of channeling the subsidies through the exchanges, eliminate the exchanges and make all persons who would have been eligible for the exchanges able to use their subsidies to purchase Medicaid. More . . .

Medicaid is of course subject to the Hyde Amendment so there will be no need for a Stupak Amendment. That disposes of that problem.

It also disposes the Mandate problem. Either folks are mandated (or auto-enrolled) into a public insurance program or we can make the use of the subsidy voluntary. Eligibility (or auto-enrollment) for Medicaid Buy-In eliminates the need for the pay out to the insurance companies, as they will not be getting any of the money - it will all go to Medicaid.

Sure, we will not have reformed health insurance, but the current bill will not either. And we will be getting 900 billion dollars to less well off people so that they can get insurance. 30 million people will get health insurance. That will save lives.

I can not believe any one except folks possessed of sociopathic indifference would put the exchanges above insuring 30 million people and saving lives.

Speaking for me only

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    Mandates (5.00 / 4) (#2)
    by Coral on Wed Dec 16, 2009 at 12:55:45 PM EST
    Mandates are really problematic without much stronger regulation and premium price control. The whole issue of cost seems to be focused

    a. on the cost of medical services and medicine--primarily billed to insurers

    b. the cost to the government of the new program, subsidies, etc.

    However, how much everyday people are paying out of pocket to insurers, even though it's important to lefty blogs and progressives doesn't seem to surface all that much in the mainstream debate.

    The way the public discussion has developed mystifies me. There seems to be absolutely no connection, however tenuous, between the debating points in Congress and the press and the real problems Americans are facing with the current Kafka-esque health care mess.

    You wonder where all this is going to end.

    Apropos of maybe nothing: while reading (5.00 / 1) (#49)
    by oculus on Wed Dec 16, 2009 at 03:23:20 PM EST
    today on line about California's Healthy Families program, I discovered states accepting fed. stimulus funds were barred from cutting Medicaid.  Interesting, huh?

    heh, nice close (none / 0) (#1)
    by andgarden on Wed Dec 16, 2009 at 12:50:06 PM EST
    I suspect that even this proposal would prompt a substantive defense of the magic exchanges.

    this would be (none / 0) (#12)
    by Molly Pitcher on Wed Dec 16, 2009 at 01:12:41 PM EST
    Far too simple and easy!

    If Congress refused to pass a Medicare buy-in (none / 0) (#3)
    by MO Blue on Wed Dec 16, 2009 at 01:01:00 PM EST
    using the excuse that the rate Medicare paid providers was too low, the chance of this happening is about nil since Medicaid rates are even lower.

    By that logic (none / 0) (#4)
    by Big Tent Democrat on Wed Dec 16, 2009 at 01:02:11 PM EST
    they are going to kill the bill because of the Medicaid expansion. Nelson still might do that of course.

    It is my understanding (none / 0) (#10)
    by MO Blue on Wed Dec 16, 2009 at 01:11:46 PM EST
    that the Senate refused to increase the expansion of Medicaid to 150% of poverty level which was initially proposed as a trade for removing the public option. Still time, as you say, to water the coverage down more.

    They can't completely eliminate the Medicaid expansion since it is one of the few selling points left.

    Also, I have yet to see logic as a requirement for the Senate decisions.


    Sure (none / 0) (#16)
    by Big Tent Democrat on Wed Dec 16, 2009 at 01:30:49 PM EST
    I am not sure why folks think this is a done deal though. There is a lot more yet to extract.

    I don't believe it is a done deal (5.00 / 1) (#22)
    by MO Blue on Wed Dec 16, 2009 at 01:32:55 PM EST
    I believe it will be made even worse before all is said and done.

    "Other than that, Mrs. Lincoln, (5.00 / 2) (#39)
    by Anne on Wed Dec 16, 2009 at 02:54:03 PM EST
    how did you enjoy the play?"

    Other than the Dems stripping the bill of the Medicare buy-in and the public option, not bringing Medicaid poverty rate up, killing re-importation of prescription drugs, not raising the medical loss ratios, keeping the individual mandate, how are we liking health care reform?

    Seriously, how much longer are we going to cling to the fiction that there's something inherently positive about the bill as it's shaping up?

    I don't know about anyone else, but I simply cannot wait (that's sarcasm, in case you were wondering) for the GOP ads depicting a triumphant Barack Obama taking credit for this historic reform bill, juxtaposed with clip after clip of real people who don't look happy that they were forced to buy cr@ptastic insurance they can't afford and still does not get them the care they need.  Yes sir, that is going to be one cringe-worthy campaign.


    You forgot about the lifetime cap. (none / 0) (#41)
    by oculus on Wed Dec 16, 2009 at 02:58:03 PM EST
    Prohibiting a lifetime cap may still (5.00 / 1) (#48)
    by MO Blue on Wed Dec 16, 2009 at 03:20:10 PM EST
    be in the bill. The change as I understand it is that they are now allowing annual caps in the Senate bill.

    Bankruptcies due to medical expenses for people who have insurance are acceptable to our Democratic controlled Senate.


    That is my understanding (5.00 / 1) (#50)
    by Zorba on Wed Dec 16, 2009 at 03:25:59 PM EST
    as well, MO Blue.  Annual caps, but no lifetime cap.  However, the annual cap becomes moot if, say, you're suffering from cancer, need lots and lots of expensive surgery/radiation/chemo, exceed your annual limit, cannot afford to continue with your therapies, and die by the end of the year.

    I meant to write (none / 0) (#51)
    by Zorba on Wed Dec 16, 2009 at 03:27:35 PM EST
    "....the lifetime cap becomes moot...."  Proofreading is my friend, I should try to use it.  ;-)

    My governor (none / 0) (#5)
    by me only on Wed Dec 16, 2009 at 01:02:26 PM EST
    a Democrat would disagree with the expansion of Medicaid (I know this because he has already stated it).  He isn't possessed of sociopathic indifference.

    I'm assuming they would get help (5.00 / 1) (#8)
    by cawaltz on Wed Dec 16, 2009 at 01:11:12 PM EST
    funding an expansion of Medicaid. Personally I prefer a federal plan because I think Medicaid is piecemeal with each state doing there own thing making it hard for there to be enough to put downward pressure on the market exchange. That being said it isn't totally worthless to expand Medicaid.

    I was making a reference (none / 0) (#13)
    by Big Tent Democrat on Wed Dec 16, 2009 at 01:13:56 PM EST
    to a Village Blogger's phrase for anyone who does not sign onto the Lieberman bill.

    It was a joke.


    Obviously Fremulon Insurance (none / 0) (#24)
    by me only on Wed Dec 16, 2009 at 01:33:16 PM EST
    is not one of your clients...

    I actually kind of like (none / 0) (#6)
    by cawaltz on Wed Dec 16, 2009 at 01:07:39 PM EST
    how you get around Stupak and maybe if more people were invested in the Medicaid program the states would do something to fix the darn system so it more workable. The downside is in alot of states Medicaid makes it really hard to find a provider. In the two states I'm familiar with the people I know have ONE doctor in their area that takes it. This could be problematic if adding alot more people to the rolls. I also know in Florida they have a ridiculously high amount your bill must be before Medicaid pays on your behalf. Hopefully states like Florida would tweek that or people might see a Medicaid buy in as worthless.

    It would (5.00 / 2) (#9)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 01:11:39 PM EST
    only be "valuable" if the premiums were cheaper than the tax penalty ;-).  Then, you'd at least save money while getting worthless insurance.

    And yes you're right.  For your above-state reasons, buying into Medicaid is just another way of providing "coverage" while not actually providing healthcare.

    And I will say that after spending the first 18 years of my life as a Medicaid recipient.


    I don't get how this matters? (none / 0) (#7)
    by me only on Wed Dec 16, 2009 at 01:10:57 PM EST
    What is so different about the Stupak Amendment and the Hyde Amendment?

    "The we do not accept Medicaid" (none / 0) (#27)
    by KeysDan on Wed Dec 16, 2009 at 02:12:04 PM EST
    or Medicare, or any other component of the "health care reform" legislation needs to be addressed, in any event, with a "no cherry-picking provision" for providers.  To be a participating provider in any federally-subsidized or supported insurance program requires participation in all.  

    now that's an interesting idea (none / 0) (#11)
    by beowulf on Wed Dec 16, 2009 at 01:12:11 PM EST
    Didn't the CBO tell the House the most cost-effective way to increase coverage was by expanding Medicaid?  

    Congress could mandate providers who accept Medicare to accept Medicaid as well.  In exchange, they could raise Medicaid  provider rates to Medicare (or Medicare +5 ) levels and pay at least a portion of that by allowing Medicaid programs buy drugs through the VA.  The federal government (the Pentagon and Public Health Service buy via the VA contract) pays a third less than Medicaid for identical prescription drugs.

    I suspect (5.00 / 1) (#36)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 02:52:02 PM EST
    that requiring Medicare-accepting providers to accept Medicaid patients would only reduce the number of providers who accept Medicare.  

    ...and fewer and fewer providers are accepting Medicare as it is.  Providers claim they LOSE money on Medicare patients (and that it's even worse with Medicaid patients).  Medicare patients are being SQUEEZED into appointments because doctors are making up for poor reimbursements by taking more patients per hour.

    Besides that, forcing doctors to accept certain patients isn't all that good for patient care. Would you want to go to a doctor -- say, an oncologist -- who is forced to accept you? The only way that doctors will willingly change and accept patients is if reimbursements improve via some mechanism...maybe a tax break like we give the banksters.


    better than no doctor (5.00 / 1) (#55)
    by beowulf on Wed Dec 16, 2009 at 06:49:16 PM EST
    If you had a cancer and your options were was self-paying for treatment till you ran out of money, or going to an oncologist who was forced by Medicare or Medicaid to see you-- I think you'd get over the doctor's poor bedside manner.

    If a doctor squeezes you in for a few minutes but can order the necessary tests, prescriptions or consults,  you're in a much better place than someone who can't afford any medical treatment.  After all, even a pissed off doctor doing his job is a doctor doing his job.

    Its like being on a ship, no has a right to a first class cabin, but every passenger has a right to a seat in a lifeboat.    Of course, even the lifeboat rule isn't a law of physics or something. It wasn't until two years after the Titanic sinking that international law  was enacted by treaty that requires every ship to carry enough lifeboats for every passenger.  I'm sure shipowners didn't like being forced to do that either.


    An (none / 0) (#58)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 10:04:09 PM EST
    oncologist who sees you for 5 minutes cannot do his job.

    Sure they can (none / 0) (#42)
    by me only on Wed Dec 16, 2009 at 02:58:10 PM EST
    and my Father in law would take one Medicaid patient and be in compliance.

    Now that you've proposed it (none / 0) (#14)
    by magster on Wed Dec 16, 2009 at 01:16:54 PM EST
    Lieberman will be against it because the word "left" is in the name of your blog.  

    Way to go BTD!

    We'll end up with the .... (5.00 / 1) (#26)
    by trillian on Wed Dec 16, 2009 at 02:05:48 PM EST
    Senate bill 'as is', and Lieberman is doing ...exactly what Obama wants him to do....doing the dirty work for him.....

    Obama, who was described as upbeat in what was an otherwise serious meeting, responded: "Why don't we all begin to have some fun? Let's pass this bill."

    Obama thanked Lieberman privately for his statement issued earlier Tuesday pledging support for the bill as long as the Medicare expansion and public option were eliminated from the bill, Lieberman said.

    I had this same thought this morning (none / 0) (#15)
    by s5 on Wed Dec 16, 2009 at 01:17:48 PM EST
    A Medicaid buy-in is a good idea. Where do I register my vote?

    Pysicians for a national health Plan (none / 0) (#17)
    by samsguy18 on Wed Dec 16, 2009 at 01:31:26 PM EST
    pnhp.org Have several studies.... one under the title "Crusade" (92000 participants)showed medicaid patients receive inferior healthcare compared to medicare and private insurance.

    what about versus patients with no insurance? (5.00 / 1) (#56)
    by beowulf on Wed Dec 16, 2009 at 06:54:28 PM EST
    No one would be surprised if Medicare and private insurance provide better healthcare than Medicaid, but by definition the uninsured have neither.  If Medicaid offers superior healthcare than no insurance, than a Medicaid buy-in is a worthwhile reform.

    No doubt about it (none / 0) (#20)
    by Big Tent Democrat on Wed Dec 16, 2009 at 01:32:35 PM EST
    I would have to say this depends on the (none / 0) (#21)
    by Militarytracy on Wed Dec 16, 2009 at 01:32:50 PM EST
    state administering it since Colorado Medicaid was one of the first to pay for children to receive Titanium Rib treatment.

    It also (none / 0) (#40)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 02:57:22 PM EST
    depends on the treatment being given.  If a Medicaid patient needs a treatment and doctors are champing at the bit to build creds doing that treatment, they're more likely to accept Medicaid patients, basically do it pro-bono.  Medicaid then can afford to provide the treatment.

    If they won't allow a Medicare buy-in (none / 0) (#18)
    by Militarytracy on Wed Dec 16, 2009 at 01:31:41 PM EST
    Why would they allow a Medicaid buy-in?

    Cheaper (none / 0) (#19)
    by Big Tent Democrat on Wed Dec 16, 2009 at 01:32:15 PM EST
    Okay, now I'm curious (none / 0) (#23)
    by Militarytracy on Wed Dec 16, 2009 at 01:33:14 PM EST
    "Crusade study referenced above" (none / 0) (#25)
    by samsguy18 on Wed Dec 16, 2009 at 01:52:22 PM EST
    Targeted cardiac patients nationwide.

    Just a thought: (none / 0) (#28)
    by andgarden on Wed Dec 16, 2009 at 02:24:16 PM EST
    I was always prepared to accept some form of a trigger, assuming it would be pulled. That may be where the House progressives draw the line on the Conference Report, and I could probably accept that.

    But we'd lose Lieberman! And gain Snowe. (none / 0) (#32)
    by steviez314 on Wed Dec 16, 2009 at 02:35:25 PM EST
    Hey, I can accept that too.

    I think Snowe would say no to a trigger now (none / 0) (#34)
    by andgarden on Wed Dec 16, 2009 at 02:44:05 PM EST
    too. The momentum has shifted.

    She would always say No (none / 0) (#45)
    by Big Tent Democrat on Wed Dec 16, 2009 at 03:06:45 PM EST
    to a trigger that would, you know, actually trigger.

    Probably (none / 0) (#47)
    by andgarden on Wed Dec 16, 2009 at 03:11:59 PM EST
    But I am not sure how far that point was pressed. In any case, as you've observed, we still don't have 60 votes. I can't wait to see what the next concession is? Force the states to pass onerous abortion restrictions to get Medicaid money?

    Listening to Landrieux yelling with Dean tonight (none / 0) (#53)
    by steviez314 on Wed Dec 16, 2009 at 06:12:52 PM EST
    on Tweety, I'm thinking that now that Dr. Dean says kill the bill, the conservatdems will vote for it.

    Kinda like a reverse-Joe maneuver.


    So why not put it in anyway, and when it doesn't (none / 0) (#54)
    by steviez314 on Wed Dec 16, 2009 at 06:17:01 PM EST
    trigger within 2 years, run the candidates in 2012 against the insurance companies, and for an amended, immediate trigger (51 votes only needed there I bet.)

    I bet it would be easier to run on "Trigger it NOW" than on "Add a Public Option".  It's always easier to change 1 page than it is to add 100.


    BTD ever use medficaid? (none / 0) (#29)
    by jedimom on Wed Dec 16, 2009 at 02:24:31 PM EST
    no one on Earth would BUY into Medicaid

    it is a third world country right here in the USA

    Who has used Medicaid and would buy into it? Not I

    That makes it a perfect compromise (5.00 / 1) (#33)
    by andgarden on Wed Dec 16, 2009 at 02:43:21 PM EST
    In fact, better if you shout that opinion loud. What the Republicans are terrified of is that people will see it as a genuine alternative.

    Buying into Medicaid (5.00 / 1) (#43)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 03:01:24 PM EST
    If the Medicaid premium is cheaper than the tax penalty, and you don't quite qualify for the tax penalty exception, then buying into Medicaid makes sense.  You wouldn't exactly USE the Medicaid, you'd simply buy into it as a cheaper tax.

    Man, what a screwed up system that would be.


    Yup (none / 0) (#46)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 03:10:05 PM EST
    I think that's exactly what's happened in Colorado.

    Colorado docs wanted to do the surgery as much as possible.  Thus, they'll likely do it on the cheap.  Thus Medicaid will cover it.Link.

    The surgery has only been available in Colorado since 2006.

    When I was searching for this, I found as a sideline, that Aetna covers the surgery for TIS, but NOT for scoliosis.  Reading the article, how do you separate the two?  But it's good wiggle room for the insurance companies to use to deny care.  But I digress.


    like SECTION 8 (none / 0) (#30)
    by jedimom on Wed Dec 16, 2009 at 02:29:13 PM EST
    Like offering people a BUY IN to Section 8 housing

    it is something you have for emergencies not something you budget for

    anyone who had a dollar would pay for a private dr with it not up their medicaid coverage


    Or a buy-in... (none / 0) (#37)
    by kdog on Wed Dec 16, 2009 at 02:52:06 PM EST
    for food stamps.

    Maybe we could morph medicaid from piss-poor emergency only coverage for the broker than broke (plain broke ain't broke enough to qualify)into something worth buying into though...kind of a medicaid in name only, stealth public option.

    What Medicaid pays providers would have to be upped significantly.


    Get more people in it (5.00 / 1) (#44)
    by Big Tent Democrat on Wed Dec 16, 2009 at 03:06:09 PM EST
    and it is a distinct possibility.

    Well I lived (none / 0) (#38)
    by me only on Wed Dec 16, 2009 at 02:53:47 PM EST
    in Section 8 housing without government support.  (Does that qualify as buying in?)  Got to see a dead body, the SWAT team, a burning car and regular drug deals.  Nice hardwood floors and great pickup basketball were the only advantages.

    Shoot (none / 0) (#52)
    by CST on Wed Dec 16, 2009 at 03:55:17 PM EST
    I've seen all that and never been in Section 8.  Just lived in cities my whole life.

    Kinda like cr@ppy insurance without the medicare prices...


    And if you ever wonder (none / 0) (#60)
    by me only on Thu Dec 17, 2009 at 01:59:09 PM EST
    why I moved to the gated suburbs just remember that comment.

    Then (none / 0) (#31)
    by Big Tent Democrat on Wed Dec 16, 2009 at 02:32:05 PM EST
    it is not a problem and the health reform issue stay alive.

    Medicaid as an inferior good (none / 0) (#57)
    by beowulf on Wed Dec 16, 2009 at 07:48:55 PM EST
    If everyone knows that no matter how much or little they make or whether they have a job or not, they'll always have access to basic medical coverage, then Medicaid for all is a good thing to shoot for.  If a person has the money to buy better healthcare coverage, they certainly will-- this makes Medicaid a classic "inferior good" (items for which rising income leads to lower consumption).

    if the government provided Medicaid coverage on demand for every citizen, everyone would pay for it (via taxes) and everyone could access it-- but probably wouldn't if they could afford better options.   Of course, there are other ways to provide government-funded healthcare-- Native Alaskan villages have clinics run by the  "Community Health Aide Program" that is even cheaper than Medicaid, $1100 a year per person in 2007.  But that might be considered a bit too inferior a good. :o)  http://www.akchap.org/


    So (none / 0) (#59)
    by TeresaInSnow2 on Wed Dec 16, 2009 at 10:06:38 PM EST
    the answer is to put people into a crappy underfunded system when it takes them months to see a doctor?  And make them pay for it or pay a tax penalty?

    Maybe that's okay for you.  Me, I've been on Medicaid....spent the first 18 years of my life on it.

    It's not an answer, but I must say, I love armchair quarterbacking.  Very entertaining.


    I am beginning to notice a pattern here... (none / 0) (#35)
    by Nathan In Nola on Wed Dec 16, 2009 at 02:51:57 PM EST
    Either the Senate or Obama or both goes and does something really stupid and spineless that sends a terrible red flag for the kind of bill that we will eventually get stuck with. BTD sees it right away, says, "This is terrible and here's why..." Shortly afterward, though, his optimism gets the better of him and he puts up another post: "Okay, that was really bad, but we're not totally screwed because someone might still remember why we sent them there and figure out that they can stick up for themselves and do X." But either later that day or early the next day (it doesn't take long for hope to die in this debate), it becomes clear that X will never happen. Rinse, repeat, ad nauseam.

    You know, it's funny: The other day I was reading some article about how a group of Teabaggers was having a press conference about killing the bill, and I remember thinking, "Wow, I think I actually agree with you guys..."