Amid the busy start to Trump’s second term, something that has received relatively little attention is the Republican Party’s budget bill working its way through Congress.
I suspect the reason that Medicaid is so popular is that masses of people conflate it with Medicare. This is really a product of Republicans giving Democrats an opening on health care but of longer standing. If this works for Democrats, they should thank Paul Ryan. At any rate, controlling this issue is a poisoned chalice. Screwing around with payment systems like insurance and welfare won't fix the deeply broken health CARE system. To do that you have to deal with corporate medicine, health deserts and most intractable of all, lifestyle. And do all this into the teeth of demographic decline.
I’d add lawyers to your list of parties. I’d like to see a compare and contrast with the US, Canada, Australia, New Zealand, the UK, in addition to Europe as to: the cost and prevalence of ligation, malpractice insurance premiums, and the estimated cost of defensive medicine. The cost of our litigious society has yet to be fully presented.
In terms of the cost of our system, you can also blame health care attorneys who work with MBAs in hospital system C Suites to maximize revenue in a way that does not improve care or cost for patients. The provider tax, which Michael does not mention, was likely conceived in the C Suite with the advice of health care lawyers.
Agree with both of you. Defensive medicine is probably the biggest contributor but impossible to quantify. Provider taxes are mostly a state level scam. The revenue is recycled into higher reimbursements to providers which allows the state to claim more Federal match.
Aren't the cuts to provider taxes (the state level scams) one of the things they are arguing about in the OBBB? By definition it seems these are a form of waste or abuse, yet politically getting rid of the scam is being classified as part of "Medicaid cuts"? If something was a scam, shouldnt politicians be capable of explaining that to the American people? (dont laugh) Legislators increasingly hire communications specialists instead of policy specialists, so surely the comms people can get the messaging right . . .
That is my understanding but also the whole scoring issue for reconciliation bills is a scam of a bigger sort. For that matter doing business this way at all is a scam.
100 agree. I wish more pundits would write about the fact that all we get are huge reconciliation bills in which one unpopular party tries to undo what the last unpopular party did. If the "current policy" ploy somehow gets approved by the parliamentarian, we are in more serious trouble fiscally. Wish more Americans cared about fiscal matters, but they seem to care more about keeping any benefit Congress gave them and what new goodies they propose to get re-elected.
AI: OB malpractice insurance (depending on state) can cost up to $80,000-150,000. Because of the statute of limitations (up to 21 years in some states), OBs carry insurance even after they retire.
Michael, would you acknowledge there is more complexity in Medicaid payment systems and the ACA generally than is captured in an opinion poll? There are legitimate problems with the Medicaid provider tax, for instance, and enhanced premiums subsidies are unsustainable. And NONE of the proposed Democratic programs actually lower health care costs, they merely have the federal government subsidize premiums, something our country cannot afford. I also think there is a difference between the original Medicaid program and how it was expanded under the ACA, with the feds paying MORE for people who are NOT disabled, pregnant, children, etc.
The ACA did dramatically slow the growth of health care costs. Out of pocket maybe not so much as premiums often went up, but there were many cost containment measures that saved a lot of money. Health care still costs twice what it should, tons of room for improvement, but the ACA slowed it considerably.
In what ways and for whom did it save money? I am sincerely asking as someone who pays a lot for healthcare and have only seen costs and my premiums rise. I was charged $20k last year for less than 24 hours at the hospital. I owed/owe $4000 out of pocket. I was disappointed Congress gave in to unions and large employers and got rid of the Cadillac tax. That would have pressured the big players to negotiate for lower prices and premiums to keep their benefits in the tax free range.
A lot of preventive care saves money as it's more costly to fix problems after they become chronic. Renal failure/diabetes. Health care costs generally which had been rising at 20% to 30% per year flatlined for many years. Hospitals with high readmission rates were hurt financially such that they learned to fix people before discharge.
Much depends on how much money you make, for the poor it was great. Medicaid costs the enrollee nothing. Many could go to a doctor for the first time. Premium subsidies for ACA participants brought the cost of insurance way down. We used to pay more for insurance than the mortgage, and $10K deductible, plus they'd deny coverage until you died. Self employed had a horrible time with health insurance.
Hospital costs went way down as they didn't have to cover the indigent with money from elsewhere, like the uninsured.
It didn't help high income who had to pay full price and it included costly things.
I agree for the poor it was great and I believe in expanding coverage especially for the poor and disabled. PLEASE show me data that hospital costs went way down . . . Hospital systems and insurance companies have no incentive to lower costs if the federal government is going to subsidize premiums. I was charged $16,000 for less than a day at the hospital. My share was $4000. Hospital prices have gone up faster than EVERYTHING else in this country. In that, the ACA failed to make health care AFFORDABLE, unless you are poor/make up to 400% poverty or work for a large company where you have a $100 deductibe and get a luxury health plan tax free. If the government is going to subsidize, it MUST work to bring down prices of premiums. Sorry for the shouty all caps. I am trying to learn about others' experiences. And I always appreciate conversations in which I learn. The ACA did a lot of good things, but is a far cry from making the system work.
Obamacare added a lot of mandatory services to insurance policies. These benefited those who were paying for such out of pocket but caused premiums to rise.
Fan of your posts, but beg to differ on this one. The ACA simply moved costs, first to those who provided their own insurance. Then eventually everyone's premiums soared. Single proprietors saw their premiums rocket first. Because most people obtain insurance thru work, they have no idea of the actual expense.
Currently $25-30K a year for a family of 4, with each person, not the family , having a $5K deductible, if you are self employed. In our family in a decade, 1 person has hit the deductible ever. Families essentially face $50K a year, out of pocket, before much is covered, but a check up. Medicines soared, and many that were covered prior, are now out of pocket.
The ACA basically dumped 100% of healthcare costs on 50% of the nation. We lived in CA when it began, and our doctor volunteered at a clinic that took the lowest Obamacare plan. She noted south of San Diego, 300K people had the lowest plan, and at the time 6 pediatricians in a 60 mile span would accept it. Not 6 practices , but 6 kid doctors. If your child had a sinus infection in Feb, they were likely to see a doctor in May, It led to tele health, because there was literally no other way for poor families to get their hands on antibiotics. They had a card in their wallet, but no better access to care than before.
We are more chronically sick as a population, than ever before. Diseases of the aged, like diabetes, which has more than doubled since Obamacare, arrive much earlier in life, which means they must be treated longer, with more dire outcomes. Reps do not have a better idea, but Obamacare is not the answer, in our experience.
It isn’t about the system, improving it, ensuring its survival and making it more efficient, it’s about using it as a political weapon to gain power. And that is all that matters. And that is one reason the people can’t stand the Dem
Party. You don’t care about the people. We saw that in spades with Biden. The Repubs have this issue also. But they won and the Dems lost. It’s about the people. Except if you are a partisan.
See the new boss, same as the old boss. A rock band that understands better than the politicians.
Well, if Medicaid is that popular, we're going to need to raise taxes to pay for it.
My suggestion is taxing the non-profit sector, which accounts for about 5% of the entire economy. Take two examples: "The American Prospect" and "The Federalist." Both are informative publications, but contributions to both are tax deductible. Why?
If you eliminate tax deductions to non-profits, then most of the money will come from the 10% of taxpayers who itemize. In case you were wondering, raising tax rates on upper income brackets won't do the trick because the rich will simply donate the money to their favorite non-profit or foundation (conveniently under their control).
Alternatively, you can fund Medicaid like Medicare, with a 1.5% payroll tax. Though, given the rate of growth in Medicaid, you can plan for that to be around 3%.
We need to look at the non-profit status of hospitals in which members of C Suite make a million dollars each per year. One commentor has suggested with the expansion of Medicaid and ACA subsidies there is not much uncompensated care. If true, how do the nonprofit hospitals and their well-compensated execs and boards justify their nonprofit status?
We had an NGO resettling unaccompanied migrant children in the city. The top 6 executives were making between $300K to nearly $700K in the Texas, doing "the Lord's work". It eventually came out they didn't vet anyone they handed kids. There are horror stories. The State shut it down, about the time Trump ending their funding, and the executives some who made upwards of of a few million bucks , walked away with a half a years unpaid rent on the building. They have no liability for handing kids to predators or modern day slave traders. Shut them all down, unless they have criminal and civil liability for misdeeds.
So called non profits are on my bad list of late. Every time I dove deep into our state's environmental funding via the BBB bill of the last administration I found orgs I'd never heard of getting many millions and it wasn't yet spent as they'd no way to actually spend the monies as they'd only learned how to set up an org and apply for grants. When I am king I'll eliminate them altogether. Rent seekers as they say. I support environmentalism, but not blowing money on nothing. Many other orgs similar. Homelessness, crime, housing, lots of salaries, nothing gets done.
There will never be Medicaid/Medicare reforms as long as we get articles like this. Should the country just head on to bankruptcy because politicians can wring votes out of being dishonest and scaring people?
Medical care in this country is under a good deal of stress and requires changes to stabilize and then increase the health of an extremely complex system. A good move for Democrats might be to get creative and develop a sound plan to move it toward stability and soundness.
But to just look for quick political points, without addressing the impending disaster, is penny wise and pound foolish. Don’t call restricting access to only legal residents a cut in Medicaid and beat the drum about how those callus Republicans are always trying to take your rights away. The problem is too serious.
Medicaid is managed by the states themselves and it's pretty horrible, but it's much better than nothing and hope to gosh you never have to depend on it. Many of the elderly in nursing homes use it when they deplete their entire savings in three weeks.
One big problem with both the ACA and Medicaid, and Medicare is that the two parties never work on any of the ongoing fixes that should be part of the programs. The parties are locked in a death struggle to do nothing, and nothing ever gets improved.
Some of the best ideas I've heard come from that conservative economist Orin Cass who had good ideas on expanding the low cost and successful public Clinics across the country.
There has to be a bottom, a point beyond where we will allow ourselves to sink. I've seen countries where the poor are untreated, it's not pretty. People with broken limbs begging in front of the hospital. We are a wealthy country, no reason to waste money and we need to spend more wisely but reducing medicaid is not how to do it.
There used to be a division of labor where Medicaid covered those who were on some sort of Federal welfare program while the states had a Medically Indigent program for those who weren't. As I understand the current proposals on Medicaid, they are not about cutting benefits but about putting more of the financial costs on the states as was the case in the old days. The nursing home problem you identify is going to get worse, given demographic trends.
So well said! "One big problem with both the ACA and Medicaid, and Medicare is that the two parties never work on any of the ongoing fixes that should be part of the programs. The parties are locked in a death struggle to do nothing, and nothing ever gets improved."
Is there a fully developed study or summary of the experience, cost, and outcomes of health ministries? In the spirit of looking at a different model, health ministries have been serving patients for decades. It would be informative to see what they are doing well that improves: customer satisfaction, patient outcomes, and the cost. And also outline their challenges or shortcomings. We have several healthcare delivery models, each should be looked at. Our authoritarian approach: everyone herded into the same big government/insurer/provider model is broken. Not impugning motives, just noting the reality.
The ACA had a provision and billions of dollars for the federal government to study innovative payment methods but it failed to produce any workable ideas after ten years. The market COULD solve some of it, but Congress and states have to act to stop market consolidations, enforce price transparency and prevent hospitals from posting ridiculous prices in response.
Other commenters have suggested sensible improvements to our healthcare system. I especially agree with the critical need for malpractice/tort reform to greatly decrease the incentive for physicians to practice defensive medicine by ordering dubious tests and procedures, all for CYA purposes. Politically that's a big challenge because almost all elected Democratic legislators receive big campaign bribes from personal injury lawyers to protect their racket.
But conservative readers here have to face political reality: a huge majority of Americans want themselves and their fellow citizens to receive necessary medical care without having to fear being financially ruined. If Democratic politicians could defy their base voters - the crazed Left wokesters - they would improve the Democratic brand and they could then campaign against the mindless anti-tax religion that is still a dominant factor in the Republican party.
The hospital industry and large employers are also fighting reform and have a solid grip on both parties. Pelosi has wanted to expand the ACA to everyone (no matter the cost) and last year Schumer killed a bipartisan, Republican introduced bill that would require site neutral payments, meaning hospitals cannot buy up outpatient clinics and physician practices and charge like those are part of the hospital, including "facility fees."
I suspect the reason that Medicaid is so popular is that masses of people conflate it with Medicare. This is really a product of Republicans giving Democrats an opening on health care but of longer standing. If this works for Democrats, they should thank Paul Ryan. At any rate, controlling this issue is a poisoned chalice. Screwing around with payment systems like insurance and welfare won't fix the deeply broken health CARE system. To do that you have to deal with corporate medicine, health deserts and most intractable of all, lifestyle. And do all this into the teeth of demographic decline.
I’d add lawyers to your list of parties. I’d like to see a compare and contrast with the US, Canada, Australia, New Zealand, the UK, in addition to Europe as to: the cost and prevalence of ligation, malpractice insurance premiums, and the estimated cost of defensive medicine. The cost of our litigious society has yet to be fully presented.
In terms of the cost of our system, you can also blame health care attorneys who work with MBAs in hospital system C Suites to maximize revenue in a way that does not improve care or cost for patients. The provider tax, which Michael does not mention, was likely conceived in the C Suite with the advice of health care lawyers.
Agree with both of you. Defensive medicine is probably the biggest contributor but impossible to quantify. Provider taxes are mostly a state level scam. The revenue is recycled into higher reimbursements to providers which allows the state to claim more Federal match.
Aren't the cuts to provider taxes (the state level scams) one of the things they are arguing about in the OBBB? By definition it seems these are a form of waste or abuse, yet politically getting rid of the scam is being classified as part of "Medicaid cuts"? If something was a scam, shouldnt politicians be capable of explaining that to the American people? (dont laugh) Legislators increasingly hire communications specialists instead of policy specialists, so surely the comms people can get the messaging right . . .
That is my understanding but also the whole scoring issue for reconciliation bills is a scam of a bigger sort. For that matter doing business this way at all is a scam.
100 agree. I wish more pundits would write about the fact that all we get are huge reconciliation bills in which one unpopular party tries to undo what the last unpopular party did. If the "current policy" ploy somehow gets approved by the parliamentarian, we are in more serious trouble fiscally. Wish more Americans cared about fiscal matters, but they seem to care more about keeping any benefit Congress gave them and what new goodies they propose to get re-elected.
AI: OB malpractice insurance (depending on state) can cost up to $80,000-150,000. Because of the statute of limitations (up to 21 years in some states), OBs carry insurance even after they retire.
Well said! Both parties are to blame for the system we have.
Oops, this comment directed at Richard's comment.
Michael, would you acknowledge there is more complexity in Medicaid payment systems and the ACA generally than is captured in an opinion poll? There are legitimate problems with the Medicaid provider tax, for instance, and enhanced premiums subsidies are unsustainable. And NONE of the proposed Democratic programs actually lower health care costs, they merely have the federal government subsidize premiums, something our country cannot afford. I also think there is a difference between the original Medicaid program and how it was expanded under the ACA, with the feds paying MORE for people who are NOT disabled, pregnant, children, etc.
The ACA did dramatically slow the growth of health care costs. Out of pocket maybe not so much as premiums often went up, but there were many cost containment measures that saved a lot of money. Health care still costs twice what it should, tons of room for improvement, but the ACA slowed it considerably.
In what ways and for whom did it save money? I am sincerely asking as someone who pays a lot for healthcare and have only seen costs and my premiums rise. I was charged $20k last year for less than 24 hours at the hospital. I owed/owe $4000 out of pocket. I was disappointed Congress gave in to unions and large employers and got rid of the Cadillac tax. That would have pressured the big players to negotiate for lower prices and premiums to keep their benefits in the tax free range.
A lot of preventive care saves money as it's more costly to fix problems after they become chronic. Renal failure/diabetes. Health care costs generally which had been rising at 20% to 30% per year flatlined for many years. Hospitals with high readmission rates were hurt financially such that they learned to fix people before discharge.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01478
But it did not help consumers, right? Our premiums went up as did hospital costs.
Much depends on how much money you make, for the poor it was great. Medicaid costs the enrollee nothing. Many could go to a doctor for the first time. Premium subsidies for ACA participants brought the cost of insurance way down. We used to pay more for insurance than the mortgage, and $10K deductible, plus they'd deny coverage until you died. Self employed had a horrible time with health insurance.
Hospital costs went way down as they didn't have to cover the indigent with money from elsewhere, like the uninsured.
It didn't help high income who had to pay full price and it included costly things.
I agree for the poor it was great and I believe in expanding coverage especially for the poor and disabled. PLEASE show me data that hospital costs went way down . . . Hospital systems and insurance companies have no incentive to lower costs if the federal government is going to subsidize premiums. I was charged $16,000 for less than a day at the hospital. My share was $4000. Hospital prices have gone up faster than EVERYTHING else in this country. In that, the ACA failed to make health care AFFORDABLE, unless you are poor/make up to 400% poverty or work for a large company where you have a $100 deductibe and get a luxury health plan tax free. If the government is going to subsidize, it MUST work to bring down prices of premiums. Sorry for the shouty all caps. I am trying to learn about others' experiences. And I always appreciate conversations in which I learn. The ACA did a lot of good things, but is a far cry from making the system work.
Obamacare added a lot of mandatory services to insurance policies. These benefited those who were paying for such out of pocket but caused premiums to rise.
Fan of your posts, but beg to differ on this one. The ACA simply moved costs, first to those who provided their own insurance. Then eventually everyone's premiums soared. Single proprietors saw their premiums rocket first. Because most people obtain insurance thru work, they have no idea of the actual expense.
Currently $25-30K a year for a family of 4, with each person, not the family , having a $5K deductible, if you are self employed. In our family in a decade, 1 person has hit the deductible ever. Families essentially face $50K a year, out of pocket, before much is covered, but a check up. Medicines soared, and many that were covered prior, are now out of pocket.
The ACA basically dumped 100% of healthcare costs on 50% of the nation. We lived in CA when it began, and our doctor volunteered at a clinic that took the lowest Obamacare plan. She noted south of San Diego, 300K people had the lowest plan, and at the time 6 pediatricians in a 60 mile span would accept it. Not 6 practices , but 6 kid doctors. If your child had a sinus infection in Feb, they were likely to see a doctor in May, It led to tele health, because there was literally no other way for poor families to get their hands on antibiotics. They had a card in their wallet, but no better access to care than before.
We are more chronically sick as a population, than ever before. Diseases of the aged, like diabetes, which has more than doubled since Obamacare, arrive much earlier in life, which means they must be treated longer, with more dire outcomes. Reps do not have a better idea, but Obamacare is not the answer, in our experience.
.
It isn’t about the system, improving it, ensuring its survival and making it more efficient, it’s about using it as a political weapon to gain power. And that is all that matters. And that is one reason the people can’t stand the Dem
Party. You don’t care about the people. We saw that in spades with Biden. The Repubs have this issue also. But they won and the Dems lost. It’s about the people. Except if you are a partisan.
See the new boss, same as the old boss. A rock band that understands better than the politicians.
Well, if Medicaid is that popular, we're going to need to raise taxes to pay for it.
My suggestion is taxing the non-profit sector, which accounts for about 5% of the entire economy. Take two examples: "The American Prospect" and "The Federalist." Both are informative publications, but contributions to both are tax deductible. Why?
If you eliminate tax deductions to non-profits, then most of the money will come from the 10% of taxpayers who itemize. In case you were wondering, raising tax rates on upper income brackets won't do the trick because the rich will simply donate the money to their favorite non-profit or foundation (conveniently under their control).
Alternatively, you can fund Medicaid like Medicare, with a 1.5% payroll tax. Though, given the rate of growth in Medicaid, you can plan for that to be around 3%.
We need to look at the non-profit status of hospitals in which members of C Suite make a million dollars each per year. One commentor has suggested with the expansion of Medicaid and ACA subsidies there is not much uncompensated care. If true, how do the nonprofit hospitals and their well-compensated execs and boards justify their nonprofit status?
We had an NGO resettling unaccompanied migrant children in the city. The top 6 executives were making between $300K to nearly $700K in the Texas, doing "the Lord's work". It eventually came out they didn't vet anyone they handed kids. There are horror stories. The State shut it down, about the time Trump ending their funding, and the executives some who made upwards of of a few million bucks , walked away with a half a years unpaid rent on the building. They have no liability for handing kids to predators or modern day slave traders. Shut them all down, unless they have criminal and civil liability for misdeeds.
So called non profits are on my bad list of late. Every time I dove deep into our state's environmental funding via the BBB bill of the last administration I found orgs I'd never heard of getting many millions and it wasn't yet spent as they'd no way to actually spend the monies as they'd only learned how to set up an org and apply for grants. When I am king I'll eliminate them altogether. Rent seekers as they say. I support environmentalism, but not blowing money on nothing. Many other orgs similar. Homelessness, crime, housing, lots of salaries, nothing gets done.
There will never be Medicaid/Medicare reforms as long as we get articles like this. Should the country just head on to bankruptcy because politicians can wring votes out of being dishonest and scaring people?
Medical care in this country is under a good deal of stress and requires changes to stabilize and then increase the health of an extremely complex system. A good move for Democrats might be to get creative and develop a sound plan to move it toward stability and soundness.
But to just look for quick political points, without addressing the impending disaster, is penny wise and pound foolish. Don’t call restricting access to only legal residents a cut in Medicaid and beat the drum about how those callus Republicans are always trying to take your rights away. The problem is too serious.
Medicaid is managed by the states themselves and it's pretty horrible, but it's much better than nothing and hope to gosh you never have to depend on it. Many of the elderly in nursing homes use it when they deplete their entire savings in three weeks.
One big problem with both the ACA and Medicaid, and Medicare is that the two parties never work on any of the ongoing fixes that should be part of the programs. The parties are locked in a death struggle to do nothing, and nothing ever gets improved.
Some of the best ideas I've heard come from that conservative economist Orin Cass who had good ideas on expanding the low cost and successful public Clinics across the country.
There has to be a bottom, a point beyond where we will allow ourselves to sink. I've seen countries where the poor are untreated, it's not pretty. People with broken limbs begging in front of the hospital. We are a wealthy country, no reason to waste money and we need to spend more wisely but reducing medicaid is not how to do it.
There used to be a division of labor where Medicaid covered those who were on some sort of Federal welfare program while the states had a Medically Indigent program for those who weren't. As I understand the current proposals on Medicaid, they are not about cutting benefits but about putting more of the financial costs on the states as was the case in the old days. The nursing home problem you identify is going to get worse, given demographic trends.
So well said! "One big problem with both the ACA and Medicaid, and Medicare is that the two parties never work on any of the ongoing fixes that should be part of the programs. The parties are locked in a death struggle to do nothing, and nothing ever gets improved."
Is there a fully developed study or summary of the experience, cost, and outcomes of health ministries? In the spirit of looking at a different model, health ministries have been serving patients for decades. It would be informative to see what they are doing well that improves: customer satisfaction, patient outcomes, and the cost. And also outline their challenges or shortcomings. We have several healthcare delivery models, each should be looked at. Our authoritarian approach: everyone herded into the same big government/insurer/provider model is broken. Not impugning motives, just noting the reality.
The ACA had a provision and billions of dollars for the federal government to study innovative payment methods but it failed to produce any workable ideas after ten years. The market COULD solve some of it, but Congress and states have to act to stop market consolidations, enforce price transparency and prevent hospitals from posting ridiculous prices in response.
Cutting the benefits to illegals, that's all.
Other commenters have suggested sensible improvements to our healthcare system. I especially agree with the critical need for malpractice/tort reform to greatly decrease the incentive for physicians to practice defensive medicine by ordering dubious tests and procedures, all for CYA purposes. Politically that's a big challenge because almost all elected Democratic legislators receive big campaign bribes from personal injury lawyers to protect their racket.
But conservative readers here have to face political reality: a huge majority of Americans want themselves and their fellow citizens to receive necessary medical care without having to fear being financially ruined. If Democratic politicians could defy their base voters - the crazed Left wokesters - they would improve the Democratic brand and they could then campaign against the mindless anti-tax religion that is still a dominant factor in the Republican party.
The hospital industry and large employers are also fighting reform and have a solid grip on both parties. Pelosi has wanted to expand the ACA to everyone (no matter the cost) and last year Schumer killed a bipartisan, Republican introduced bill that would require site neutral payments, meaning hospitals cannot buy up outpatient clinics and physician practices and charge like those are part of the hospital, including "facility fees."