No Time to Go Wobbly on “One Care”

I am reprinting an article I wrote for the new issue of Commonwealth Magazine concerning One Care, Massachusetts’ bold and risky experiment to coordinate care for the so-called “dual eligibles” who are under age 65 and disabled.  It has been a tough ride in the program’s first two years.  In this piece, I give the background and context for One Care and propose that we stay the course as the smart and right thing to do:

one-care-banner-headerBACK IN 2008, when I was working in the US Senate on national health reform, a delegation of 20 business leaders from the New England Council visited Capitol Hill to offer advice. The group’s leader was Charlie Baker, then Harvard Pilgrim Health Care’s CEO. I recall his one recommendation: “You have to do something about dual eligibles because they are one of the most important and expensive pieces of the puzzle.”

As Massachusetts now struggles to sustain One Care, its nationally significant dual-eligibles demonstration project that launched in October 2013, Gov. Baker’s hope is happening. Given the project’s rocky and difficult first 18 months, he could be forgiven for wondering if he could rewrite that wish. Continue reading “No Time to Go Wobbly on “One Care””

Will 61 Be the Charm? The New Republican Effort to Gut the ACA

[Note: This post was first published on the Health Affairs Blog.]

For the 61st time since 2011, Congressional Republicans are moving legislation to undermine and dismantle key elements of the Affordable Care Act (ACA). This time, though, will be different.

First, this will be the first time Republicans will use the budget process known as “reconciliation” to advance repeal. Using a budget reconciliation bill prevents Democrats from filibustering the legislation in the Senate, meaning only 51 votes are needed for passage in expedited debate.shampoo

Second, this will be the first time that the House and Senate both pass similar legislation to damage the law. As a result, this will be the first time that anti-ACA legislation will reach President Barack Obama’s desk. The President’s veto of this measure is guaranteed, as are the needed votes in the House and Senate to sustain his veto. So this will be another exercise in ObamaCare-Kabuki Theater with some new twists.

What’s In The Reconciliation Package?

The key elements in the legislation, developed by three House Committees (Ways and Means, Energy and Commerce, Education and the Workforce) including: Continue reading “Will 61 Be the Charm? The New Republican Effort to Gut the ACA”

Department of Connecting Dots: Koch … Alaska

Two disconnected stories came across my screen yesterday so closely in time, I could not resist putting them together.  See if you agree.

Story One concerns the conservative advocacy organization, Americans for Prosperity, that is possibly the leading advocacy group in the nation fighting the Affordable Care Act/ObamaCare.  Funded by the billionaire brothers, Charles and David Koch, AFP is perhaps the leading group in the nation fighting to prevent red states from expanding their Medicaid programs to poor uninsured people.  On the other side are hospitals, physicians, insurance companies, business groups, consumers and just about everyone else except the conservative activists led by AFP and the Koch brothers’ money.

Lest you think they are starting to give up, see this from Reuters:

“If there’s one thing that exasperates Tim Phillips, the president of the conservative advocacy group Americans for Prosperity, it’s when outsiders don’t understand he’s in it for the long run.

“The group, founded by the billionaire industrialist brothers Charles and David Koch, has been around for 10 years already, and its presence is growing. Each time the number of people signed up to volunteer for AFP reaches a certain threshold in a state, AFP opens a field office there. It now has offices in 33 states, and at its national Defending the American Dream Summit on Friday and Saturday in Columbus, Ohio, Phillips joked that he was ready to accompany the handful of volunteers from Hawaii back home to do the difficult task of opening an office there.

“In an interview Saturday, Phillips made it very clear: There’s no chance AFP is going to give up on its efforts to repeal President Barack Obama’s healthcare legislation, the Affordable Care Act.

“’When I said long-term, I meant it,’ Phillips said. “We have never stopped.”

“Congress passed the healthcare legislation in 2010 and it took effect just under four years later. The Supreme Court has since ruled twice its provisions were constitutional in cases challenging it. The U.S. House of Representatives has voted many times to repeal it, but none of those efforts has made it all the way through Congress. Public opinion polls show a majority of Americans are in favor of keeping it, and Congressional Budget Office projections show it lowering government expenditures on healthcare in the future. But Phillips has a different perspective.

“’The Left has been pushing for government-run healthcare since the 1920s,’ he said. He doesn’t think AFP’s struggle will have to last that long.

“’We’re in year six of a healthcare battle.’ he said. ‘It’s may be a 10- or 12-year battle.’”

Continue reading “Department of Connecting Dots: Koch … Alaska”

Cake and Cupcakes for Medicare and Medicaid’s 50th Anniversary

Fifty years ago this Thursday, July 30th 1965, President Lyndon Baines Johnson signed into law legislation creating two new national health insurance programs, Medicare and Medicaid.  Fifty years later, these programs appear as recognizable and durable as any monuments in Washington DC.  That’s an illusion because there’s little difference between the Lincoln and JeffersLBJ HSTon Memorials today versus 1965.  On the other hand, Medicare and Medicaid today look radically different from the law signed by LBJ as former President Harry Truman looked on.

If there is one constant in Medicare and Medicaid, it is change — constant, persistent change to fit the needs and preferences of the time.  Both programs have been works in progress for 50 years, and so it continues.

The law’s original metaphor, coined by then-House Ways & Means Chairman Wilbur Mills (D-AR), was the “three layered cake.”  The bottom layer was Medicare Part A — the original Democratic proposal for hospital insurance, funded by new employer/employee Social Security taxes deposited in a new Part A Hospital Insurance Trust Fund.  When reference is made to “Medicare going broke,” it means this Trust Fund. When debate over the legislation that became the Affordable Care Act/Obamacare began in 2009, the Fund was scheduled to have insufficient funds by 2017 — last week’s new Trustees’ report now pegs the Fund’s financial reserves as solid through 2030.


The second/middle layer was Medicare Part B — payment for physician services, funded by enrollee premiums and government revenues.  During the original Medicare debate, Democrats wanted what became Part A and Republicans pressed for what became Part B.  It was Wilbur Mills’ inspiration to combine them into a single program.  This past March, Congress passed a new law overhauling physician payment in Part B.  Parts A and B make up what is often called “Traditional Medicare,” a federal insurance program with no state government involvement.

The third layer was Medicaid — a new federal-state program to provide medical benefits for low income mothers and their children who were on “welfare” or public assistance.  The law required the feds to set national rules and left administration to states with lots of discretion.  A more appropriate metaphor — less tidy than Mills’ — would have been to cupcakesdescribe Medicaid as 51+ (including DC and US territories) marbled cupcakes.  The saying goes: “if you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.”  Because of changes brought by the ACA, Medicaid today is more a national program with uniform standards than ever — still it is 51+ marbled cupcakes, each one different from the rest.

In 1965, Medicaid was an afterthought — a make-shift, temporary caboose on the bold, new federal Medicare system that many expected/hoped would expand to cover all Americans within several years.  In his definitive book on Medicare’s creation, “The Politics of Medicare,” Ted Marmor did not even mention Medicaid.  Today’s ACA-reformed Medicaid covers more than 70 of 320 million Americans (Medicare covers about 54 million). It is the nation’s largest health insurance program covering 40% of all our children and paying for 40% of the nation’s births, the largest payer for nursing home and long-term care, and so much more.  Sure, 19 states are still refusing to expand Medicaid as permitted by the ACA.  History tells us they will come around — the last state to join original Medicaid was Arizona, and not until 1982, 17 years after the program’s creation!  I continue to predict that all 50 states will be in no later than 2020.

More than Medicaid, though, Medicare has become the undisputed driver of health system reform in the US and around the world.  In the 1965 law, Medicare was required to pay hospitals and physicians their “usual, customary, and ordinary” fees, a mega-inflationary scheme if there ever was one.  In 1983, under “conservative” President Ronald Reagan, Medicare became the world’s biggest government agent for administered prices with the creation of the Inpatient Hospital Prospective Payment System (PPS), with Diagnostic Related Groups (DRGs) as the price-setting tool.  Today, DRGs are one of the most familiar hospital payment forms around the globe.

Today, Medicare is much more than traditional A+B.  It now includes C+D — (“new” Medicare).  C has had several names during its 40+ year history, prominently “Medicare+Choice” between 1997 and 2003, and today’s “Medicare Advantage” by which enrollees get Medicare benefits managed by a private health insurer, now covering about one third of all Medicare enrollees.  Part D was established by Congress in 2003 to provide, for the first time, an outpatient prescription drug benefit for enrollees managed by private drug plans. There’s no mandate, but if enrollees don’t sign up when first eligible, they pay increasingly higher premiums for the rest of their lives!  But it’s not a mandate, so they say.

Understanding the politics of Medicare is much more straightforward if you remember this: Democrats like A+B, traditional Medicare because it is government-paid fee-for-service which keeps insurance companies out of the picture (except for Medigap coverage — another topic!) and tend to dislike C+D because of these programs’ reliance on private health insurers.  By contrast, Republicans detest A+B as government bureaucracy, and love C+D because both rely on private insurers.  Understand this, and everything becomes easier.  Below, I also add Medicaid and the Exchanges to the political mix.

Your Easy Guide to the Politics of Federal Health Programs

Democrats Republicans
Medicare A+B (traditional Medicare) +
Medicare C+D (new Medicare) +
Medicaid +
ACA Health Exchanges + ?@%&!

Republicans also tend to loathe and despite Medicaid because it is government provided health insurance.  One irony is that, today, most states require that Medicaid enrollees get  their coverage through private Medicaid managed care plans run by private insurers.  Go figure.

While the ACA established yet a third pillar to the US health landscape in the form of Health Insurance Exchanges/Marketplaces to provide subsidized private health insurance to Americans unable to get insurance elsewhere, Obamacare also made dramatic changes to both Medicare and Medicaid, reinforcing my premise that these program always have been, and continue to be, works in progress.

The ACA not only expanded greatly who is eligible for Medicaid (to all non-elderly with incomes below 138% of the federal poverty level [$15,654 in yearly household income for a single adult]), it established for the first time national eligibility and enrollment standards.  Though the Obama Administration is permitting all manner of experiments in conservative states (i.e.: Arkansas, Iowa, Indiana) hoping to “get to yes” on eligibility expansion (because of the 2012 US Supreme Court decision that made the ACA expansion an option rather than a requirement for states), Medicaid looks more like a national program today than ever before.

Meanwhile, the ACA accelerated Medicare’s role as a national delivery system reform engine through initiatives such as Accountable Care Organizations (ACOs), bundled payments, penalties on hospitals with high rates of readmissions and patient injuries, and much more.  In US health policy today, Medicare is  driving the reform agenda as the private sector follows and innovates in Medicare’s footsteps.

As someone who follows US health policy developments closely, I am constantly amazed by the daily and incessant deluge of news relating to both Medicare and Medicaid.  Lots of these stories offer hyperbolic predictions of impending doom and calamity — this one I read today by Joe Antos of the American Enterprise Institute predicts that Medicare will be the next Greece!

Fifty years of Medicare and Medicaid and the pace of change just keeps accelerating — for better and worse.  While many Americans fervently wish we could just have one solid federal health insurance pillar, now we’ve got three (not even counting the Veterans Administration and Tricare).  I’m an optimist and believe that our system is  getting better.  I think that’s true most and not all the time.  What’s undeniable is that our major health programs are works in progress, constantly moving and changing.

Here’s hoping that in the next 50 years, we will find a more stable and durable solution for all Americans.

11.7 + 11.7 = 23.4 million Enrolled via ACA

We had previously  learned in March that an estimated 11.17 million Americans took advantage of private insurance coverage offered through the ACA’s exchange/marketplaces through the second enrollment period ending in February.  Today, we learn that a similar number, 11.7 million, represents the number of low income Americans newly enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) between 2013 and February 2015.  That’s Pappy_O'Daniel's_logo23.4 million Americans directly benefiting from the expansion provisions of Titles I and II of the ACA.

Take a look at the report released last Friday by the US Department of Health & Human Services with the details, including state by state breakdowns.  Some details:

  • From 57,594,096 in September 2013, Medicaid/CHIP enrollment reached 70,515,716 in February 2015
  • 29,245,000 of the 70.5 million are children, nearly 30 million
  • States expanding Medicaid saw enrollments jumps averaging 27%, while the states refusing to expand saw only an 8% increase
  • Eye-popping increases — Kentucky 85%; Oregon 69%; Nevada 67%; New Mexico 51%; Washington 50%; Arkansas and West Virginia 49%; Rhode Island 41%
  • Surprises among non-Medicaid expanding states — North Carolina and Tennessee 16%; Montana 14%; Mississippi 12%
  • Just depressing — Alaska, Nebraska, Utah <1%; Wyoming 1%; Alabama and Missouri 3.5%.

Of course, if the resisting states had expanded Medicaid, we would see approximately 4 million more already enrolled in Medicaid — they will come, it’s just a matter of time (Montana is only the latest, not the last).

Republican lawmakers in DC, by and large, despise Medicaid — during the ACA debate in 2009 on Capitol Hill, Sen. John Cornyn (R-TX) called it the “gulag” of the American health care system.  They say this in spite of the fact that, these days, most of the 70+ million Americans enrolled in Medicaid get their coverage through private managed care plans.  Oh well, as Governor Pappy O’Daniel remarked in the movie, “O Brother, Where Are Thou,” “there ain’t no accountin’ for taste.”  The Romans, more elegantly, would have said: “De gustibus non est disputandum.”

Here’s something that’s hard to dispute.  More and more Americans are coming to appreciate Medicaid as a reliable and affordable source of health insurance coverage.