Results for “medicaid wars”
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The Medicaid wars continue

From Sarah Kliff:

Sandra Decker, an economist with the Center for Disease Controls, recently poured over the 2011 National Ambulatory Medical Care Survey, which asks doctors whether they would accept new Medicaid patients.

What she found could spell trouble for the health care law: More than three in ten doctors – 31 percent – said no, they would not.

Her research, published this afternoon in the journal Health Affairs, is the first that has ever given a state-by-state look at doctors’ willingness to accept Medicaid.

The problem, of course, is that higher demand will be pressing against a relatively fixed supply.

Medicaid wars, continuing

Phil Galewitz and Matthew Fleming surveyed all 50 states to find out how Medicaid budgets are changing. They found that 13 states had made cuts this year..Seven have Democratic governors; six are led by Republicans. Three are in the south and an equal number are in New England. Two, California and Connecticut, seem to really like the Medicaid program: They volunteered to start the health law’s Medicaid expansion early, well before it’s required in 2014. Others, like Louisiana and Florida, are not fans at all: They plan to sit out that Obamacare provision.

All told, it’s pretty hard to find any narrative that explains why these states have cut their Medicaid programs, aside from some broad truths: Budgets are still squeezed and Medicaid is eating up a growing chunk of state spending.

From Sarah Kliff, here is more.

CBO forecasts Medicaid Wars

In 2022, for example, Medicaid and the Children’s Health Insurance Program (CHIP) are expected to cover about 6 million fewer people than previously estimated, about 3 million more people will be enrolled in exchanges, and about 3 million more people will be uninsured…

Only a portion of the people who will not be eligible for Medicaid as a result of the Court’s decision will be eligible for subsidies through the exchanges. According to CBO and JCT’s estimates, roughly two-thirds of the people previously estimated to become eligible for Medicaid as a result of the ACA will have income too low to qualify for exchange subsidies, and roughly one-third will have income high enough to be eligible for exchange subsidies.

There is more here.

Aaron Carroll on Medicaid Wars

Enough people have linked to this piece that I thought I should write a response, which you will find under the fold…

To start with a general remark.  Often defenders of ACA request some kind of conservative engagement with the policy, rather than voting for the 34th (?) time for outright repeal with no coherent story of replacement.  I’ve laid out a coherent scenario of how ACA could evolve into something which I consider better, and actually with only modest changes to the law itself.  The mandate gets narrowed, the system as a whole evolves into means-tested vouchers (which proponents such as Zeke Emanuel favor), and possibly HSAs are given a larger role again.  I say states will try to limit Medicaid growth, not that they should but that probably they can over the longer run.  Defenders of the current ACA don’t have to favor my analysis, but in fact what I get back is sheer annoyance from Carroll, repetition of Carroll from various others, and an attack from Krugman, with no substantive engagement on the policy proposal at all.

Carroll writes five times that he is annoyed by my piece, but in hardly any of those cases is he disagreeing with any position I took.  Let’s go through them one-by-one:

I get a bit annoyed when people claim that we can’t “afford” more government intervention or, god-forbid, single-payer. That kind of statement willfully ignores the fact that every country that has MORE government intervention spends LESS.

I most definitely did not say this and in fact I mentioned that single payer systems lower cost.  Spending more on Medicaid, however, will not save the U.S. money (the Oregon study shows this), whether or not we can normatively “afford” it.

I get a bit annoyed by the claim that an expansion of government insurance leads to lines and waiting when lots of countries have universal access and less of a wait-time problem than we do.

A significant influx of people into Medicaid, under current institutions, will lead to more queuing.  That is true whether or not you think other countries with single-payer have big queueing problems.  What I wrote was this:

Unfortunately, Medicaid has some of the worst features of single-payer systems. Typically, a single-payer system will bargain down medical prices, thus adding to affordability, but at the risk of having long lines of patients waiting for care. As it stands now, though, the low reimbursement rates of Medicaid already lead to long lines, or an inability to find a good doctor altogether, while the higher reimbursement rates of Medicare and private insurance keep health care costs high.

It’s even carefully worded “…at the risk of having long lines of patients waiting for care.”  Supply elasticities are positive and so single-payer systems do run this risk.  Yet I am clear that in critical regards the systems of other countries get the better end of this deal compared to the United States.

Another bit:

I get a bit annoyed by blanket claims that doctors won’t accept Medicaid. Such statements often ignore the fact that the majority of Medicaid beneficiaries are children and pregnant women. We don’t need all types of doctors to accept Medicaid patients in equal numbers. They also ignore the fact that lots of doctors won’t accept new patients with Medicare or private insurance, either.

It is very difficult to find a good doctor in northern Virginia who takes Medicaid and I speak from personal experience (helping others).  Or try any number of basic websites, with common quotations such as “Finding a Medicaid doctor constitutes a challenge…”  Medicaid dentists are hard to find.  Try calling say the Washingtonian “best doctors” list and see how many of them take Medicaid.  Large numbers of doctors do take Medicaid but overall they tend to be much worse and there are also problems with queuing.  Think about it: why would the lower payers end up first in line?

There is more annoyance:

I get a bit annoyed when people just claim government programs are “unpopular”. Like Medicare? I don’t think so. Is there any evidence that Medicaid is unpopular? I’d like to see it. Personally, I think that the fact that (a) all 50 states have bought in over time and (b) the Supreme Court just ruled that threatening to take it away is “coercive” speaks to the opposite. Additionally, polling shows the opposite of what Tyler (and lots of others) suggest.

I am sorry but this is a total “read fail.”  I am saying Medicaid (not “government programs” or “Medicare”) will become increasingly unpopular.  (In fact I am known for arguing that big government as a whole is quite popular.)  Every day in the newspaper there is handwringing by governors, not all Republican ones, about wishing to limit or escape Medicaid obligations.  A lot of them would prefer to get block grants and spend the money elsewhere (a simple question for Carroll: if Medicaid is so popular with voters, there is no reason to fear block grants to the states, right?  Voters surely will insist that Medicaid spending be kept at current levels or perhaps even increased.)  Daily Kos serves up plenty of evidence for the lukewarm support for Medicaid, as does Ezra Klein: “But, for a host of reasons, Democrats worry that Medicaid is more endangered than people realize.”  Also note how skimpy Medicaid coverage is in many states.  A lot of states don’t really try to cover poor adults, without children, at all.  Frankly this is standard fare, especially on the left, but somehow if I write it he gets annoyed.

If you poll people and ask them whether they favor health care for the poor, of course they will say yes.  The bottom line is this: right now we are borrowing about forty cents of every dollar spent.  As we move toward fiscal balance, which are among the most vulnerable programs?  Defense spending may be cut somewhat, but Medicaid is far more vulnerable than either Social Security or Medicare.  I didn’t know that was under dispute and in fact it really isn’t.

Some more annoyance from Carroll:

I get a bit annoyed at the blanket acceptance of the awesomeness of the free market in health care, when there is no phenomenal evidence of its success. And again, those countries with less free market are cheaper, universal, and often just as good. So why are we always trying to run away from them?

That is another “read fail.”  What did I call for in the column?

We would then have government-subsidized and mandated catastrophic insurance, and a freer market for other health care expenditures. We might even return to a health savings account approach on the noncatastrophic side.

I also note in the column that is not my first best, but we Americans probably cannot get easily to a first best system (for me a Singapore-style system, with single payer on the catastrophic side rather than mandates for private insurance purchase).  My accompanying blog post even noted that the HSAs could be supplemented with government funds, if it was so desired.

The real argument of the column is that ACA will fall apart for political reasons because it creates too many different groups with different treatment.  The “mood affiliation” of the column is something other than celebration of ACA, and so Carroll pulls out all of the old chestnuts and attacks them, rather than responding to the actual argument.  Basically he should go back and reread the piece itself.

Medicaid Wars, Episode IV

While the resistance of Republican governors has dominated the debate over the health-care law in the wake of last month’s Supreme Court decision to uphold it, a number of Democratic governors are also quietly voicing concerns about a key provision to expand coverage.

At least seven Democratic governors have been noncommittal about their willingness to go along with expanding their Medicaid programs, the chief means by which the law would extend coverage to millions of Americans with incomes below or near the poverty line.

Here is more.

Surgery price wars in Oklahoma City?

I don’t have deep background knowledge on this particular hospital, but here is a new and interesting article:

An Oklahoma City surgery center is offering a new kind of price transparency, posting guaranteed all-inclusive surgery prices online. The move is revolutionizing medical billing in Oklahoma and around the world.

Dr. Keith Smith and Dr. Steven Lantier launched Surgery Center of Oklahoma 15 years ago, founded on the simple principle of price honesty.

“What we’ve discovered is health care really doesn’t cost that much,” Dr. Smith said. “What people are being charged for is another matter altogether.”

Surgery Center of Oklahoma started posting their prices online about four years ago.

Click here to see the online prices at Surgery Center of Oklahoma.

The prices are all-inclusive quotes and they are guaranteed.

“When we first started we thought we were about half the price of the hospitals,” Dr. Lantier remembers. “Then we found out we’re less than half price. Then we find out we’re a sixth to an eighth of what their prices are. I can’t believe the average person can afford health care at these prices.”

Their goal was to start a price war and they did.

Their first out-of-town patients came from Canada; soon everyday Americans caught on.

Here is a bit more:

Dr. Smith said federal Medicare regulation would not allow for their online price menu.

They have avoided government regulation and control in that area by choosing not to accept Medicaid or Medicare payments.

I would like to know more about this example (maybe Cherokee Gothic can go buy something there), but the article is here and some further coverage is here.  For the pointer I thank Jake Seliger and also Craig Fratrik and Timothy Miano.

Stories to watch for in 2013

Here is a list from The Guardian.  Here is an FT list.  My list looks more like this:

1. Economic turnarounds in the Philippines, Sri Lanka, Indonesia, and possibly Pakistan and Myanmar.

2. Pressures for secession in Catalonia, and a potential crisis of the Spanish state.

3. East Asian belligerence, with more hawkish leaders in the three major countries.

4. There is actually a non-trivial chance we totally blow it on the debt ceiling.

5. The continuing rise of machine intelligence and the general recognition of such as the next major technological breakthrough.

6. Significant positive reforms in Mexico on education, foreign investment, and other matters too.

7. Political collapse in South Africa.

8. Continuation of America’s “Medicaid Wars,” over state-level coverage, combined with the actual implementation of much more of ACA.  Continuing attempts in Rwanda, Mexico, and China to significantly extend health care coverage to much poorer populations.

9. The return of dysfunctional Italian politics, combined with the arrival of recession in most of the eurozone economies, including France and Germany.

10. The ongoing barbarization of North Africa, including Mali, Syria, and possibly Egypt.  And whether any of these trends will spread to the Gulf states.

11. Whether China manages a speedy recovery and turnaround.

12. Watching India try to overcome its power supply problems, its educational bottlenecks, and its low agricultural productivity.

13. Seeing whether Ghana makes it to “middle income” status and how well broader parts of Africa move beyond resource-based growth.

14. Whether U.S. and also European political institutions can handle the intensely distributional nature of current fiscal questions.

Those are some of the main stories I will have my eye on, but of course I expect to be surprised.  I suppose Israel and Iran should be on that list somehow, North Korea too, but I don’t find that thinking and reading about it yields much in the way of return, compared to a simple “wait and see.”

Addendum: Here is Matt’s list.

Assorted links

1. Western Oklahoma markets in everything; “In other classes, students who don’t pass an exam the first time are allowed to try again. And none of the exams in the two-week format are monitored.”

2. The book marketing campaign of Tim Ferriss.

3. Twitter as weapon.

4. More on the Medicaid wars, a high stakes game of chicken.

5. The culture that is living in guilt in Paraguay.

6. The Manzi list.

Assorted links

1. Summary of the new Robert Gordon paper on stagnation, with good charts and graphs, and further coverage by Annie Lowrey here.  Paul Krugman also comments.

2. Groupon coupon for “The Anger Room,” markets in everything.

3. Andrew Gelman on different ways of plotting income data.

4. Michael Blowhard seems to be blogging again, here, under “Paleo Retiree.”

5. Sumner on Balding, Sumner on Wang, and Caplan responds to Dickens.

6. The Medicaid wars come to dentistry.