Medicaid Cuts Won’t Just Hurt the Poor

Breaking Obamacare_full

The Medicaid cuts in the Senate Republican’s “new and improved” Better Care Reconciliation Act (BCRA) are not just cruel and unpopular, but they also threaten to undermine a thriving private insurance market, which is something Republicans claim to support.

In all the recent outrage over the Senate bill, no one mentioned a central fact about Medicaid: More than half of all Medicaid recipients receive their coverage through private insurance companies, who contract with state Medicaid agencies for a set fee per beneficiary. This means that the insurance companies both take on the risk and reap the rewards. And Medicaid expansion has been profitable for insurance companies. (Our ongoing research supports this finding, but we can’t provide details here while we pursue academic publication).

KFF Medicaid Map

The Medicaid/CHIP program provides health insurance for 20% of the U.S. population. In some states, more than a quarter of residents are covered by the program. In 2016 health insurers filing with the National Association of Insurance Commissioners (NAIC) reported nearly 40 million Medicaid members, representing 54% of Medicaid beneficiaries (In 2016 monthly Medicaid enrollment averaged 73.8 million).  Private insurer participation in the Medicaid market has grown significantly since the early 2000s (along with overall Medicaid enrollment). In 2001, only around a quarter of Medicaid members were covered by private health insurers.

The current Senate bill proposes not just to roll back ACA Medicaid expansion, but also to impose per capita caps on the funds states could receive. A longer term projection of the effects of the BCRA by the Congressional Budget Office (CBO) estimates Medicaid funding cuts of 35% by 2036.

WP Fed MEdicaid Spending chart
Source: Washington Post

Are Medicaid insurers making money by providing low-quality care or denying services? Medicaid opponents would have us believe the system is broken, that few doctors will accept Medicaid patients and those who do, provide inferior healthcare.

One particularly notorious claim, that Medicaid is actually worse than no insurance, is based on data from a single study. Critics have similarly latched on to the few other reports that seem to support their viewpoint, conveniently ignoring the dozens of academic papers that show positive effects of Medicaid expansion.

Recent pieces in The New York Times and the Los Angeles Times do a good job of explaining what the “negative” studies actually say and how they’ve been misrepresented. Yet the naysayers persist. See for example this article published last week.


A new survey of Medicaid recipients further dilutes the negative depiction of Medicaid, with the majority of respondents indicating high levels of satisfaction with their healthcare. The National Medicaid Consumer Assessment of Healthcare Providers and System (CAHPS) survey included over 270,000 adults enrolled in Medicaid in the fall of 2013. The survey sample represented 46 states and included four categories of Medicaid recipients: 1) people with disabilities, 2) dual Medicare-Medicaid enrollees (the elderly), 3) non-disabled adults in managed care, and 4)non-disabled adults in fee-for-service medical care.

MSS Table

The managed care members (those covered by private insurers) reported satisfaction levels comparable with the total sample results. Non-disabled adults enrolled in managed care were slightly more likely to report they were able to access care and had a primary healthcare source than those in fee-for-service Medicaid.

In his defense of the Senate healthcare bill, vocal Medicaid opponent Avik Roy praised the plan for replacing Medicaid expansion “with tax credits so that low-income Americans can buy the coverage of their choice at an affordable price.” At the heart of Roy’s argument is a belief that private insurers (the market) can do a better job than government bureaucrats.

But when it comes to Medicaid, private insurers are already doing that job – not just administering funds, but taking on the risk and managing the care of millions of Medicaid recipients. They are profitable and their customers are satisfied. So why are Republicans intent on undermining the one part of the Affordable Care Act that is working for both insurers and insured?

Why is subsidizing coverage on the individual market so much more acceptable than paying for similar (or even better) coverage through Medicaid? Is a bronze-level marketplace plan with a high deductible and co-pays and limited provider networks really better than a Medicaid plan with similarly narrow networks but no out-of-pocket costs?

Proponents of single payer healthcare would like to have insurance companies removed from the U.S. healthcare system entirely. Realistically, however, any universal healthcare plan we are likely to see in the near future will involve insurance companies. Health insurers have the necessary infrastructure and the expertise to manage the unwieldy beast that is the U.S. healthcare system. And good luck getting universal healthcare through Congress (even a Democratic Congress) without insurance industry by-in. In Medicaid we already have a model for a successful public-private partnership.

Why Insurance Companies May Provide Our Best Path to Universal Coverage

Don’t demonize insurance companies. I know it’s tempting. After all, they are trying to make money off of people’s health. But guess what? We live in a capitalist society and this is the system we currently have. Some type of single payer (and yes there are many versions, just look at the different countries in the EU) may be the ultimate progressive goal. But we can’t get there from here overnight. In fact, the only way we can get there is probably by bringing the insurance industry along.

The success of Medicaid Expansion under the Affordable Care Act is due in no small part to insurer participation in the Medicaid marketplace. Insurers specializing in the Medicaid market are profitable, and that’s a good thing.

Who do you think covers most of the people on Medicaid and many on Medicare? Who has the expertise? State Medicaid agencies contract with insurers to cover Medicaid beneficiaries. The insurance companies take on the risks, not the states. Similarly, many Medicare recipients chose to be covered by Medicare Advantage plans run by private insurers. Insurance companies are already deeply embedded in our so-called “entitlement” programs.

Health Wealth

Right now everyone is worried about how to keep insurers in the individual market. The ACA originally provided several mechanism to help insurers deal with the uncertainty of the individual marketplace, including Risk Adjustments, Reinsurance, and Risk Corridors. You can find a good explanation of these three programs here.

The Risk Corridor program was supposed to last three years, ending in 2016. But it never really got a chance to work, because of a provision added to a must-pass 2015 budget bill by the Republican congress, requiring risk corridors to be revenue neutral. (At the time, Senator Marco Rubio characterized the risk corridors program as a bailout for insurance companies.) As a result, the federal government owes insurers billions of dollars, meant to offset losses on the exchanges. Several lawsuits are currently in progress. Is it any wonder some insurers have left the individual marketplace? Funding the risk corridor program and extending its life a few more years could help reverse this trend.

If the Feds aren’t up to the task, another solution for states with too few insurers offering policies on the individual marketplace is the “public option.” While this may seem like a more radical option, that’s not necessarily the case. I see two possible results:

  1. Insurers would out-compete the public option, rendering it obsolete

  2. Insurers would flee such markets, leaving only the public option.

But guess what? If that happened who do you think states would look to run their “public option” plans?

I keep seeing calls for “Medicare for All,” but why not make Medicaid available for everyone? After all, Medicaid in its current form (following ACA expansion) is the closest thing we have to what we all claim to want—a basic minimum level of healthcare for everyone. If you can afford more or have an employer who wants to offer you a better plan, then great (see the German system for example), but for everyone else, why not build on the part of the Affordable Care Act that already works best?

I can already anticipate some of the objections:

Giving people government handouts takes away their incentive to work.

Data on Medicaid expansion has shown this premise to be untrue. The majority of non-elderly non-disabled adults receiving Medicaid do work. They just earn too little to afford health insurance. And those who don’t work often have good reasons, like they are students or caregivers.

By expanding Medicaid to everyone, I’m not necessarily saying it should be “free” for everyone. But cost should not be a barrier to basic insurance coverage. People shouldn’t have to choose between healthcare and other necessities?

But people don’t appreciate free insurance or don’t use it wisely, aka they need “skin in the game.”

My short response to this is look at what happened when Indiana tried to charge Medicaid recipients small sums ($1 or $2) for their coverage. The bureaucratic costs outweighed the benefits.

The “skin in the game” hypothesis also assumes that people behave rationally when it comes to their health. But they don’t. They avoid going to the doctor because of high co-pays and deductibles, then end up in the emergency room when they get really sick. Or, they refuse to go to the emergency room when they should because of the high cost. They don’t comparison shop.

Medicaid reimbursements are too low/Most doctors don’t take Medicaid.

Whether this is true or not, should this be the main determinant? Everyone complains that healthcare costs keep going up. But then they complain when a program succeeds in cutting them. Plenty of doctors are willing to accept Medicaid. Doctors who treat low income patients consider Medicaid Expansion a game changer. They no longer have to scramble to get care for their patients. Hospitals also seem more than willing to accept Medicaid’s reimbursement rates. Yes, they might pass the cost on to others. But what do you think they did before, when they had much larger amounts of uncompensated care?

I’m no expert on Medicaid, and I am the first to admit “Medicaid for all who want it” is a long shot. But Medicaid is the part of the ACA that is currently working. The robust Medicaid market is helping prop up the individual marketplace. States that expanded their Medicaid programs have seen their individual marketplace perform better (with lower premiums). Support from Republican governors in Medicaid Expansion states certainly contributed to the widespread opposition to the AHCA.

 As we look for ways to strengthen our healthcare system and move towards universal health insurance, we should build on the success of Medicaid expansion.

Trumpcare Takeaway: Stakeholders Matter

The main lesson we should take away from the failure of “Trumpcare” (or “Ryancare”) is the importance of stakeholders. When groups representing every type of stakeholder (medical professionals, hospitals, patients, and insurers) all came out against the American Health Care Act, its fate was pretty much sealed.

By now I think everyone can agree that the American Health Care Act (AHCA) was never intended as serious legislation. The utter failure of GOP lawmakers to consult with stakeholders, not just in the past two months, but at any point during the last seven years, made it clear from the beginning that they were not really interested in replacing the Affordable Care Act (ACA) with a real healthcare plan, so much as a political “win.”

In contrast, before voting on the ACA, Democrats spent nearly a year holding hearings, listening to experts, and getting buy-in from stakeholders (doctors, patients, hospitals, insurers).

RIP Trumpcare2

The Republican leadership’s bypassing of the legislative process not only shows disregard for the people they purport to represent, but it also reveals just how little many members of Congress know (or care) about basic economics, much less healthcare economics. After listening to hours of “debate” over the past few weeks, I’ve come to the conclusion that most Republican House members (and probably some Democrats) don’t have the first clue how our health insurance system actually works, much less how changing it might effect their constituents.

Contrary to Republican nostalgia, I don’t think most Americans want to move backwards. The ACA protections (no exclusion for pre-existing conditions, essential health services, no lifetime caps, yearly out-of-pocket maximums) are the new standard. No amount of extolling the “free market” and “freedom to chose” will convince people they are better off without these ACA protections. In fact, the more protections Republican leadership gave away, to try and win over the Freedom Caucus, the more they spooked moderates in their party who feared the political repercussions of taking healthcare away from their constituents. And rightly so. By Thursday only 17% of the public supported the AHCA. By cancelling the vote numerous Republican members of the House were saved from voting against the interest of their own constituents.

Over the past few weeks Republicans couched their opposition to the ACA in terms of “freedom.” What they failed to recognize is that yes, Americans want freedom—the freedom to not worry about how they’re going to pay for healthcare.