Tag: Medicaid

Blog Posts (15)

February 10, 2017

The Affordable Care Act: It will not depart the same way it entered.

By Kathy Greenlee, JD
I recently learned the Irish superstition that you should exit by the same door through which you entered. The Affordable Care Act will most likely not have that option. The door it entered is closed.
I also recently revisited the unusual circumstances that allowed the ACA to become law. In early 2010, the Democrats held a 60-vote majority in the United States Senate. Then, in August, Massachusetts Senator Ted Kennedy died. In the election for his successor, Massachusetts elected Scott Brown, a Republican. Between the November election and Scott Brown’s swearing in, the Senate approved the ACA. When Senator Brown took office, the Democrats lost their super majority. The House had already passed the law, so they quickly moved to pass the Senate bill.

Having 60 votes in the United States Senate is a big deal. The Senate rules are such that the chamber requires a supermajority – 60 votes – to cut off debate and take a bill to the floor for vote.

Law, Regulations and Money

The ACA is anchored by three things: the law, regulations and money. Currently, the Republicans have a majority but not a supermajority. They don’t have 60 votes to pull the law off the books. They do, however, have enough votes to control the money. The ACA will be made ineffective and inoperable because the funds needed to make the law work will be removed. Money supports the subsidies for qualified people who purchase insurance through the exchanges. Federal money is used to match state money for Medicaid expansion and long term care rebalancing incentives (incentives for states to purchase community rather than institutional services for long term care). It takes money to close the Medicare prescription drug plan donut hole.

The first and most active battles in Congress will focus on money. And that battle has begun. The current 2017 federal fiscal year began on October 1, 2016. But, Congress has not passed a budget for this current year. Congress intends to use the current budget to gut the provisions of the ACA that are budget related. Then, immediately thereafter, the Trump administration will present Congress with a proposed 2018 budget and Congress will begin to work that budget this summer. The ACA will likely remain on the books, but won’t be operable as a comprehensive law. The non-budgetary sections will remain but will be largely inert.

While Congress assures the money dries up, the Trump Administration can begin the process of rolling back the thousands of pages of regulations that support the implementation of the law. Repealing regulations is time and labor intensive. ACA regulation repeal will be a steady slog likely to drag on through most of 2017 and into 2018. Regulations are behemoths.

Democratic Allies Needed

As you watch events unfold, keep in mind the three anchors I mentioned earlier: the money, the regulations and the law. The Republicans in Congress and in the White House will drive the budget and the regulations. They won’t need Democratic support to do so. But, to pull the remnants of the law and to pass a new law, Senate Republicans will need to find Democratic allies to help them get the 60 votes they need to cut off debate and pass legislation. The Democrats had 60 votes when the ACA passed; the Republicans currently do not. The 60-vote door will have to be unlocked in order to make new law.

Next up: Let’s talk in more detail about an ACA budget hot topic: Medicaid.

Kathy Greenlee joined the Center’s staff as Vice President for Health Policy and Aging in November 2016 after serving the past seven years as Assistant Secretary for Aging in the U.S. Department of Health and Human Services.

November 4, 2016

Is It Fair to Reward Medicaid Patients for Receiving Flu Shots?

My son was underperforming at school, and I was gently encouraging him to try harder (if gesticulating like an over caffeinated Italian qualifies as gentle encouragement). He could not understand why I was upset: “Dad, most of my friends are … Continue reading

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August 9, 2016

Why Is Getting Healthcare Coverage So Hard?

For a great nation like the United States, it is not only embarrassing, but also morally reprehensible that there are still millions of American citizens who in principle could have healthcare coverage but are being denied that benefit for purely political reasons. Ideologically driven governors in Red states would rather defy the efforts of President Obama to expand healthcare coverage for all their citizens than provide this most basic human service to their citizens. I draw this conclusion simply because their alleged reason for refusing to expand Medicaid—that expanded coverage will be unaffordable—is simply not true. With Medicaid expansion, the federal government will significantly underwrite most of the costs and without states are on their own in the most inefficient healthcare system possible—they get no access to basic primary care but if they get acutely sick they can show up at an ER and utilize the system at time where cost is exorbitant and goals are limited. It is an abomination how healthcare has been a political football for decades while people with medical needs are allowed to suffer and die.


But it is not just patients without healthcare coverage who lack access to medical care—it is also millions of patients with coverage. Medicaid currently covers over 70 million Americans, yet many of these patients are not able to find a physician who will accept them. In a 2011 national survey of physicians, 31% were unwilling to accept Medicaid patients; in certain states the rates are much higher—for example, in New Jersey only 40% of physicians accepted Medicaid patients. When reimbursement rates are increased, these rates of physicians willing to accept Medicaid patients also rise. Clearly if we are going to expand healthcare coverage in the United States, we must ensure that physicians are provided a fair reimbursement for the services. But there are other barriers other than reimbursement.


Another important barrier is the fact that many poor patients live in areas of the country where there are shortages of physicians. Up to 60% of the underserved areas in need of primary care physicians are in non-metropolitan areas. Physicians’ reticence to work in areas with high concentrations of patients whose primary insurance coverage can be partly explained by lower than average compensation rates but not entirely. Other barriers may include most physicians wanting to live in metropolitan areas and not wanting to deal with more patients with complex issues, such poverty and poor education. Moreover, physician specialist simply make much higher incomes in larger metropolitan areas. In the past the choices of individual physicians coincided with the general health needs of society. It appears that in today’s society, there are serious health needs of large segments of society going unmet.


But even in Blue states like California, with Medicaid expansion, many patients have what looks like good health care coverage and yet are often unable to find a physician or qualified health care professional to meet their needs. This is particularly problematic for patients with mental health issues. A recent story on NPR about a mom with a 12 year-old son provides a great illustration. To start with this mom is forced to pay high copays of $75 per session for needed therapy for her son—for working people, living on pay check to pay check, serious health needs can easily go unaddressed. The 2008 Mental Health Parity Act and the Affordable Care Act (ACA) insurance companies attempted to fix some of the problems like preventing insurance companies from charging higher copays for mental health services than other services. But insurance companies still find ways to skirt the law “sometimes through subtle, technically legally, ways of limiting treatment.” The mom in this story discovered one of those ways when she tried to schedule an appointed with one of the therapists her insurance company would cover for a lower copays of $20. The problem was there were no therapists willing to accept her son. The insurance companies are at least superficially in compliance with the law, but there are no therapists, or very few, that are available for new patients. Part of the problem is that millions of new patients with mental health issues have signed up under the ACA, have coverage, but cannot find a qualified healthcare professional to care for them.


The problems to which I have alluded are characteristic of a healthcare system filled with inefficiencies and bloated costs. There are many reasons to account for why these inefficiencies exist, which I won’t get into here. But as a medical educator, I am reminded of the Physician’s Charter from the American Board of Internal Medicine (ABIM), which embraces a bold, robust set of professional obligations charging physicians to expand access to medical care for all patients and to promote social justice. Under the heading of Social Justice, it states: “The medical profession must promote justice in the health care system, including the fair distribution of health care resources.”


At my medical school we are teaching our new physicians they have an obligation to advocate for all patients and help expand access to healthcare. I must admit I am worried that the challenges they will face will be nearly insurmountable without significant change at the political level and many other policy changes, like greater parity in incomes between specialists and primary care physicians and tuition debt relief. But, patients, which includes all voters, must do our part too as citizens involved in the political process and support candidates that in turn support access to quality public healthcare for everyone. These concerns should weigh heavily in the choices we make at the voting booth this fall. Getting basic healthcare coverage for all citizens should not be this hard.




August 1, 2016

Tennessee Inmates Sue for Hepatitis C Treatment

On July 25, 2016, inmates incarcerated in Tennessee prisons filed a class action lawsuit against the state’s Department of Corrections “asking the court to force the state to start treating all inmates who have the potentially deadly disease [hepatitis C].”

The inmates are represented by several advocacy organizations: American Civil Liberties Union, Disability Rights Tennessee, and No Exceptions Prison Collective. The gist of the lawsuit centers on a claim that failure to provide inmates with what now is believed to be standard of care treatment for hepatitis C is “cruel and unusual punishment” and unconstitutional.

            The prevalence of hepatitis C in Tennessee’s prison and adult general populations have been estimated at 23% and 4.4%, respectively.  Moreover, there are more persons incarcerated in Tennessee than just the state’s prison system. One Tennessee county jail recently reported that 92% of its detainees had hepatitis C!  Tennessee counties are usually financially responsible for the health care costs of those jailed within their jurisdictions.

            From news accounts that are reporting the story the principal issue clearly is money. The medicine – which is an extremely effective cure – costs about $1000 per pill to be taken daily for 12 weeks. The estimated cost per patient is about $84,000. The total cost to the Department of Corrections is staggering given the numbers of patients that may require treatment.

            But the unstated – the implied – more pressing issue from the story is not just cost, it is fairness and justice for all Tennesseans. The Tennessee legislature is responsible for the budget that funds both the Department of Corrections and the state’s Medicaid program. To assure treatment for Tennessee inmates and not provide full coverage for Tennessee’s Medicaid population who are also infected with hepatitis C would be clearly discriminatory, and possibly would not stand up to a constitutional challenge under the Equal Protection Clause. It may place the Tennessee legislature in the untenable position of having to provide treatment for coverage for both groups or neither group, and if it opts to provide treatment to then find the unbelievable sum of money to fund the costs.

            Some Tennessee legislators and their constituents may find it a bit hard to swallow if the state funds the costs of hepatitis C treatment for prisoners and not the poor and disabled patients covered by Medicaid. Legislators and citizens may see prisoners somehow as less worthy? But the comparisons won’t stop with prisoners v. Medicaid patients, some might question the fairness of Medicaid patients being eligible for hepatitis C treatment when working Tennesseans with health insurance provided through employer-based plans are somehow less eligible for treatment, or have to incur out-of-pocket costs for treatment when prisoners and Medicaid patients do not? With the costs of treatments coming from so many pots – Medicare, Medicaid, employer-based insurance plans, federally funded programs for the military and veterans – the fairness issues that will arise with future innovative and individualized – and undoubtedly more expensive – options will only grow.

June 9, 2016

What Would Aristotle Say About the Ethics of Publicly Subsidized Puberty-Blockers?

STUDENT VOICES By Melani Shahin In October 2014, Oregon became one of the few states to cover hormone suppressant therapy for transgender minors under Medicaid. The purpose of this treatment is to temporarily suppress puberty in transgender young people via … Continue reading
October 21, 2015

Unnecessarily Uninsured

This picture, from the Kaiser Family Foundation, shows that many people who lack health insurance in the United States right now are actually eligible for either Medicaid or federally subsidized private insurance. The post Unnecessarily Uninsured appe...
October 7, 2015

Is It Fair to Reward Medicaid Patients for Doing What They’re Supposed to Do?

Most conservatives agree that Medicaid costs are too high. Most liberals agree that Medicaid patients should receive necessary medical care for free. And both conservatives and liberals agree that we should embrace ways to encourage Medicaid patients to obtain important … Continue reading

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September 10, 2015

Look What Obamacare Has Done Now

The percent of Americans without health insurance has dropped precipitously in the last few years, thanks in large part to the Affordable Care Act, a.k.a. Obamacare. This is especially true in those states that, in accordance with the law, expanded … Continue reading

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June 9, 2015

The Outlier Problem of Healthcare Spending

We have an outlier problem when it comes to healthcare spending. Sure, there are some services we provide far too often for far too many people. And in the United States, at least, most of the healthcare services we provide … Continue reading

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June 4, 2015

When It Comes to Controlling Healthcare Costs, the Government Outperforms Private Industry

When I think of the federal government, “efficiency” is rarely the first thing on my mind. But when it comes to controlling healthcare costs, we need to consider the possibility that the federal government is better at this job than … Continue reading

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