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Why Paul Ryan’s Medicaid Reform Works

by Benjamin Domenech on August 23, 2012

The selection of Congressman Paul Ryan as the vice presidential nominee for the Republican ticket has brought the issue of Medicare reform to the forefront of people’s minds. But Medicaid is next up, according to the Wall Street Journal:

Medicaid provides health insurance to more than 50 million poor Americans and nursing home coverage to six million seniors and Democrats will portray any “cuts” as heartless. The Agenda Project Action Fund, which ran the infamous tv ad showing Paul Ryan shoving an elderly woman over a cliff, is now running ads in up-for-grab states like Wisconsin. The spots warn of Medicaid cuts that would adversely affect hundreds of thousands of seniors in the state and claim that Madison “will lose $14 billion in funding.”

Earlier this year, Barack Obama berated the Ryan Medicaid cuts as well. Among the victims, he says, are “someone’s grandparents who, without Medicaid, won’t be able to afford nursing home care. … Many are poor children. Some are middle-class families who have children with autism or Downs syndrome. Some are kids with disabilities so severe that they require 24-hour care. These are the people who count on Medicaid.”

The Ryan budget is hardly radical: it would block grant Medicaid to states much like the successful welfare reforms in the 1990s. States would get less federal money, and no more dollar-for-dollar match on wasteful expenditures. In exchange, they would get far more flexibility in how that money is spent. So far 29 Republican governors have sought that deal – fewer dollars for less Washington rules. Rhode Island, a state that received a waiver from federal Medicaid rules, has saved millions of dollars and improved care to seniors. “Medicaid is by far our biggest cost driver in our budget,” complains Florida’s Republican Governor Rick Scott. “We can improve services and run the program easily with billions in cost savings here in Florida if the feds let us.”

The truth is that most Democrat and Republican governors alike would be willing to trade less federal funding in return for more freedom and flexibility for their Medicaid programs. One of the reasons for that bipartisan undercurrent of agreement on the need for flexibility, rather than just throwing money at an already broken entitlement system, is that we now have examples of policy approaches beyond simply managed care to lower Medicaid costs and increase the quality of care. Chief among these examples is Florida’s pilot program, which you can read about here.

Here’s the story, in brief: A little more than six years ago, then Gov. Jeb Bush established a pilot program in five big counties in Florida with a total overhaul of Medicaid. (This plan has actually been endorsed by some key Obama administration HHS officials, so it’s not some instance of right-wing extremism.) The population involved is quite large, roughly 300k people on Medicaid – bigger than the total programs in 17 states. The program has received a wealth of attention from policy wonks but little mainstream coverage, in part because Gov. Crist never touted it, as it wasn’t his program. Thankfully, that’s beginning to change, and the Foundation for Government Accountability is beginning to highlight the successes of the program.

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Is Your State Expanding Medicaid?

by Benjamin Domenech on August 9, 2012

Above is an updated version of our map outlining which states are leaning toward, or leaning away from, expanding Medicaid under PPACA.

Below the fold, the following list was provided by the fine folks at FreedomWorks.

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Maine Clashes with Feds Over Medicaid

by Benjamin Domenech on August 1, 2012

This may very well end up being litigated:

The LePage administration Wednesday laid out what it says is a clear-cut legal argument for allowing Maine to make cuts to its Medicaid program despite a provision in the Obama administration’s health care reform law that prohibits states from scaling back existing Medicaid services.

Maine’s Department of Health and Human Services on Wednesday filed paperwork with the federal Centers for Medicare and Medicaid Services requesting approval for Medicaid cuts that Republican lawmakers approved this spring and Gov. Paul LePage signed into law as part of a supplemental budget package.

“We fundamentally believe this is a very straightforward request that is absolutely within the state’s prerogative to make,” Health and Human Services Commissioner Mary Mayhew told reporters at a news conference.

Meanwhile, Democrats repeated Wednesday that they thought the cuts violated federal law, and a Health and Human Services official from former President George W. Bush’s administration said he thought it’s unlikely the Obama administration will allow Maine to make its desired cuts.

The LePage administration is requesting what is known as an amendment to its Medicaid State Plan that makes about $20 million in Medicaid cuts to balance the state budget. The cuts, planned for Oct. 1, would eliminate coverage for 19- and 20-year-olds, tighten income eligibility requirements for low-income parents and scale back Medicaid access for elderly residents who also qualify for Medicare benefits.

This would have a significant impact on other states should Maine prove successful. More information is here.

How Medicaid Works, According to Utah’s Gov. Herbert

by Benjamin Domenech on August 1, 2012

Legislators frequently ask me what I mean when I write that implementation of a PPACA exchange means ceding control to Washington, DC along the lines of what they experience with Medicaid. Here’s an amusing story from Utah Gov. Gary Herbert to illustrate what that’s like.

So Herbert’s administration serves a Utah population which is both much younger and much more technologically adept than the average Medicaid population. Herbert decides that one way to achieve some minor but easily accessed savings is to shift to a paperless Medicaid system – to use email instead of mail. They commission a study and find that savings would run around $7 million a year – not huge, but probably worth doing. But even to do something this minor, Herbert has to receive approval from HHS and Kathleen Sebelius.

Herbert and his staffers begin the begging process, which all states must do in this situation, heading to DC on bended knee to request this small degree of flexibility.  Utah even extrapolates the study out to the national scale, finding that if applied across the states, going paperless could save around $1 billion a year, which is approaching real money in Washington. They wait for an answer.

A couple of months later, Sebelius writes to tell Herbert that no, he may not go paperless, no permission is granted.

She wrote him via email.

The Medicaid Albatross

July 24, 2012

Paul Volcker and Richard Ravitch report on the fiscal crisis facing the states, with a familiar culprit involved. From the WSJ: This state-federal program that increasingly pays for middle-class health care is the major albatross. Spending has grown faster than the economy every year since the 1960s, 7.2% annually over the last decade. It is […]

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RGA Chair Sends Thirty Questions on Implementation to HHS

July 11, 2012

You should read this letter from Virginia Gov. Bob McDonnell which lays out a litany of questions from the states to U.S. HHS Sec. Kathleen Sebelius on exchange implementation and Medicaid.  There are seventeen questions about exchanges, and another thirteen about Medicaid, and a healthy skepticism about the workability of the current plan: “We also […]

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The Reasons States Are Rejecting Obama’s Medicaid Expansion

July 9, 2012

Over the past week, we’ve heard from a wide variety of liberal sources amazed at the idea that states would reject the billions in “free money” from the federal government to expand their Medicaid programs under President Barack Obama’s health care law. Indeed, the federal matching rate for the expansion – which covers people at […]

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Is the Medicaid Expansion Fool’s Gold?

July 3, 2012

As you’ve probably heard by now, at least fifteen governors are leaning toward rejecting the Medicaid expansion as allowed by the Supreme Court: “Seven states with Republican governors have given a flat “no” to the Medicaid expansion since the Supreme Court ruling, according to reports and press statements. States that will decline to participate include […]

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The Provider Push for Medicaid Expansion

July 3, 2012

The primary push for states to accept the Medicaid expansion isn’t going to come from legislators, but from hospitals. You can probably guess why. Hospitals and providers were expecting millions of low-income and disabled patients to join Medicaid’s ranks under health reform, but the court ruled that the federal government couldn’t withhold all Medicaid funds […]

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The Supreme Court’s Surprise Medicaid Ruling

July 2, 2012

The Supreme Court’s decision on the constitutionality of PPACA included a shocking 7-2 ruling on the Medicaid expansion, which had been widely viewed on the right as the weakest argument advanced before the Court, but nonetheless resulted in a victory for federalism. States can now reject the Medicaid expansion mandated under Obamacare while retaining their […]

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