Compromising on Medicaid Expansion: Real Alternatives, or GOP trap?

Tomorrow, the big news for the Affordable Care Act will be the opening of the state-level insurance exchanges. But the other major part of the law, Medicaid expansion, proceeds apace. Republican governors in many states have simply rejected Medicaid increases, presumably on the grounds that providing poor people with health insurance is a nefarious communist plot. However, some GOP-dominated states like Michigan or divided-control states like Arkansas are working with the Department of Health and Human Services to develop alternative routes for expanding Medicaid coverage to the working poor. The challenge for the Obama administration (and progressive activists) is to determine which plans stay true to the spirit of the ACA and which ones may dangerously undermine it.

Obviously, the biggest goal is to increase coverage, but we also need to be mindful of the various strings that conservative governors and legislators might attach to the modified plans seeking waivers from the Department of HHS. 

Medicaid expansion was originally supposed to automatically apply to all states, but the Supreme Court’s 2012 ruling on the Affordable Care Act made it optional. Not surprisingly, 14 states with unified Democratic control immediately signed up for the expansion; the opportunity to provide universal health insurance to residents under 138 percent of the poverty line fulfilled a longstanding progressive dream – all made possible by the federal government picking up 90 percent of the long-term costs.

Of 24 states under complete GOP control, only two took the traditional expansion (North Dakota and Arizona) while 17 rejected it entirely. Six of the 12 states with divided control governments agreed to the standard expansion, while three have passed for now. (Here's a handy map with the state decisions)

That leaves six states under GOP control (Pennsylvania, Ohio, Michigan, Indiana, Tennessee and Florida) and three states under with split control (Arkansas, Iowa and New Hampshire)  that are either still actively considering the expansion or have proposed a non-traditional style of expanding Medicaid more agreeable to Republican majorities.

And that’s where things have gotten interesting. Follow me below the break for details.

Adjusting to Texas Part I

So I traded this:

For this:

Ouch.
That's an Omar-Vizquel-for-Felix-Fermin-level trade. Rust Belt wins this one.

A good ACA info source

Balloon Juice has a new front pager named Richard Mayhew. He's a bureaucrat at some private insurance company someplace and a political liberal. He's also been using his inside knowledge of health insurance to write a serious of very informative posts  about the nuts and bolts of why health insurance works the way it does and how the Affordable Care Act changes incentives. The comment threads that follow are also unusually thoughtful and informative with real questions from real people about real situations.

I highly recommend checking him out. Here's a link to a collection of all of his posts.

On specific topics, see a list below:

How and why deductibles and co-payments work the way they do.

What networks are and how they affect costs.

The problem of adverse selection and how it hampered reforms in New York and other states
(THIS IS WHY WE NEED AN INDIVIDUAL MANDATE PEOPLE)

An explanation of the rationale behind Medicare Part D doughnut hole and why it doesn't work out well in practice. 

This is how the Internet ought to work.

The Affordable Care Act: Obama's greatest achievement on gender equality?

As we count down the days to the opening of the health-care exchanges, it's worth mentioning that the Affordable Care Act is easily the biggest law promoting gender equality since the Violence Against Women Act of 1994 for the Family Medical Leave Act of 1993.

Barrack Obama has taken his share of flack on women's issues. Most recently, people have challenged his record of high-level executive-branch appointments for women, which has been considerably better than George W. Bush's but weaker than Bill Clinton's. On the other hand,Obama has appointed a record percentage of female judges -- by a country mile. (He's still not appointing women at their prevalence level in the population, but he's getting close)  And the pay gap between men and women is stubbornly constant, with women (still) making roughly 77 cents on average for every man.

But starting January 1, 2014, the ACA will remove several billion dollars in annual gender discrimination.

Will the ACA's medical device tax be repealed?

Today I explore a different aspect of yesterday's topic of the Affordable Care Act's Medical Device Tax. It's more political science (the factors that influence public policy making) than public policy (how effective actual policy ideas are).

The original perspectives piece on the tax in the New England Journal of Medicine by Daniel Kramer and Aaron Kesselheim report that the U.S. Senate voted 79-20 to repeal the tax as part of its non-binding budget resolution that passed last March. The authors then note that the repeal vote was bipartisan, overwhelming, and came after an intense lobbying campaign by the medical device industry. Based on this vote, they suggest that the tax is in imminent danger of repeal.

I think this fear of repeal likely overblown for now because talk is cheap and there were too many possible factors that into each Senator's vote to repeal to figure out if a majority of Senators would have actually voted to repeal the tax if push came to shove (the fancy social science term is to say the result was overdetermined)

Chait on the GOP's desperate push to kill Obamacare

Here's a fascinating must-read on the implementation of Obamacare regarding the differences of rhetoric between the pro- and anti- Affordable Care Act factions. It's a wonderfully researched summary full of very interesting political science hypotheses waiting to be tested.

Jonathan Chait was one of the earliest, best and most thorough reporters on the ACA as it wheezed toward passage. It's only fitting that he's here writing excellent stuff at the end of the journey.

Update: Krugman nails it:

Yep, when it comes to reaching hipsters, or young people in general — I know, Katy Perry — Dems have big advantages; all that coastal cultural elite hatred suddenly turns into a big disadvantage for the right.

But that’s not all: there are also channels of influence the party of Fox News simply cannot reach: Spanish-language radio and TV, black churches (which played a big role in 2012), and more.

I don’t know whether anyone thought this out in advance, but the battle of the exchanges is indeed being fought on remarkably favorable ground for the reformers. And I, for one, find the thought of conservatives humiliated by an army of tweeting hipsters remarkably cheering.

Does the medical device tax cut innovation? Maybe sometimes -- and that's the point

In the Sept. 5 issue of the New England Journal of Medicine's correspondence section, several physicians jousted over the impact of the Affordable Care Act's 2.3 percent excise tax on medical devices. I was disappointed in the focus of the argument on the tax's effect on innovation in the medical device industry.  The entire exchange missed the broader point: how much does "innovation" in medical devices actually improve health care and how much of it is rent-seeking that siphons off patient and taxpayer dollars without helping patients?

Right now, most of my readers are probably asking, "Wait, what's this medical device tax?"

Good question. Part of the negotiations behind the ACA entailed major stakeholders in the health care industry -- hospitals and provider organizations,  health insurance companies, drug companies and medical device manufacturers to contribute to cost savings as the law was implemented. Hospital associations agreed to cuts in reimbursement rates in Medicare and Medicaid payments valued at about $155 billion from 2010-2020, health insurance companies had an annual fee levied on them that works out to about $60 billion over the same decade, while drug maker agreed to levies on branded drugs of about $27 billion. The medical device industry reluctantly acceded to a 2.3 percent tax on all sales of medical devices not available on the retail market (i.e. we're taxing M.D Anderson's newest CT Scanner and not grandma's wheelchair). The tax is projected to bring in about $20 billion over the first decade of the ACA's existence and went into effect at the beginning of 2013

I'm getting all of these details out of John E. McDonough's superb Inside National Health Reform, which is a must-read for anyone who wants to understand Obamacare. You should buy this book.

OK, now back to the debate in the New England Journal of Medicine.