The Corner

Politics & Policy

The Unmentioned Problems in ‘Medicaid for All’

From the Tuesday edition of the Morning Jolt:

The Congressional Budget Office Is Very ‘In’ Right Now

If you want healthcare reform to cost the U.S. government less than the status quo, that requires less money to go out the door to pay for other people’s health care and/or health insurance. This means someone else has to pay more, or someone else has to pay for their care or insurance entirely by themselves.

This is the core conflict of all health care debates. Some pleasant-sounding voices claim they can get “somebody else” to pay for your health care, and imply that it is free to you. The cost is actually spread to everyone, which results in either higher spending by the government (and at some point, higher taxes or higher borrowing) or higher premiums by everyone who did purchase insurance. For the vast majority of us, you’re going to pay one way or another. Pick your poison: premium, co-pay, deductible, or tax penalty for not having insurance.

Everybody screaming “Medicaid for all!” basically means, “I don’t want to pay anything for my health care.” They think of themselves as being generous.

The “Medicaid for all” crowd also usually hand-waves away the fact that a lot of doctors don’t take Medicaid. As of 2015, only 67 percent of doctors take Medicaid, and only 45 percent of doctors take new patients on Medicaid. The “Medicaid for all” fans usually answer that this can be resolved by forcing doctors to see Medicaid patients, even if they don’t like the limited reimbursement rates.

There’s also the inconvenient fact that the best study we have shows that Medicaid doesn’t actually improve people’s health. It makes them feel better by self-reported measures, and less financially stressed.  But it also had “no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk” and “found no evidence that Medicaid caused new enrollees to substitute office visits for [emergency room] visits; if anything, Medicaid made them more likely to use both.”

Yesterday’s big news was the Congressional Budget Office studying the text of the Republican health care plan, the “American Health Care Act,” and concluding that it would reduce federal deficits by $337 billion over the next ten years, but also that in the coming ten years, 24 million people would join the ranks of the uninsured.

Our Dan McLaughlin:

The whole thing is a silly system, given that CBO scores are thus classic “Washington facts” that have power totally unrelated to whether or not they are accurate. The CBO has been wrong every time in the past it has tried to project the number of people with health insurance, including being off by 24 million people when it updated its projections after the Supreme Court struck the mandatory nature of its Medicaid expansion in 2012. But rules are rules even if they require you to declare that the sun’s not yellow, it’s chicken. The projections of who will and won’t be insured don’t actually mean anything. But the projections of deficit reduction mean a lot, whether or not they are accurate – because they give the bill the procedural green light to go forward.

Avik Roy goes back and checks the numbers:

In 2010, when the Affordable Care Act was passed, CBO estimated that 21 million people would enroll in the ACA exchanges in 2016. The actual number was closer to 10 million. Even now, CBO believes that 18 to 19 million people will soon be enrolled in the exchanges, when in fact enrollment is degrading under current law, and will likely end up stabilizing at about 10 to 11 million.

Roy has offered his share of criticism of the bill, but he gives it credit for including “the most significant effort at entitlement reform in American history” and “ reduc[ing] federal spending by more than $2 trillion over the next 20 years.”

I think Megan McArdle may have the most politically sound approach, which is to try to pass a set of reforms but fail, and have Democratic obstructionism as a convenient excuse for everything that follows:

I foresee two potential futures for the current status quo. One, the exchanges where individuals buy policies could fail, leaving people unable to buy insurance. Or two, the exchanges don’t fail, and we’re left with an unsatisfactory but still operational system.

In either case, the Republicans’ best option is to wait. Why? Because what they can do now — hastily, without touching the underlying regulations that have destabilized the individual market — is worse than either of those outcomes. The partial-reform structure they think they’ll be able to get through the Senate is likely to make the problems in the individual market worse, not better. And the fact that they’ve tinkered with the program means that Republicans will take 100 percent of the blame.

So I’d wait to see if the long-feared disaster comes at the end of this year, and if it does I’d make sure that Democrats own as much of the blame as possible. If they want to block reform, make sure the public knows they did: Throw up a comprehensive bill that they can filibuster. Appoint a blue-ribbon commission to come up with a unified Republican plan. Stop the funding games the Democrats were using to prop up the exchanges. And if the exchanges collapse, say to the public: “Hey, look, we didn’t touch the individual market. It was the garbage program Democrats rammed down your throats. We tried to save it, but they wouldn’t let us.”

The Republican focus then becomes, what kind of reforms will create affordable insurance options for people when the exchanges collapse and no insurance company is willing to sell insurance on them, because too many of the remaining patients are sick and not enough customers are healthy.

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