By Hootsbuddy
Those of us doing due diligence investigating health care reform will find this article reassuring if nothing else.The writers have sterling credentials and their message, in a nutshell, is "health reformers should build on what works (Medicaid) before enacting complicated new administrative infrastructures that may or may not work (insurance exchanges for low-wage families)."
My experience is that a stunning majority of people not involved do not know the difference between Medicare and Medicaid. In fact, most Medicare beneficiaries themselves are ignorant about Medicaid, being ineligible because their assets and/or income exceeds Medicaid limits.
I can break it down in a few words.
Medicare is national insurance for MEDICAL CARE. Hence the name.
Medicaid is a euphemism for welfare. Medicaid provides financial AID (and more) for poor people.
Both are federal programs but Medicaid is administered by the states. Individual states, guided by federal policies from CMS (the Center for Medicare and Medicaid Services) determine who qualifies for Medicaid assistance along with food stamps, WIC and a range of other public assistance programs. If you just remember that Medicaid is welfare and Medicare is not you won't get confused. (And anyone who thinks that health care shouldn't be rationed needs to wake up, by the way. It's been rationed from the start and these two programs are vivid illustrtions of how it currently works.)
Now to the article in the spotlight.
These writers make such a good case for expanding Medicaid it almost makes sense to drop health care reform altogether and look for ways (read "funds") to let the existing Medicaid infrastructure carry the load. It's too late now, of course, for coitus interruptus. This season's efforts at health care reform are too close to orgasm to pull out. But this piece (no pun intended) is worth reading.
These are heady times for big concepts for transforming health care delivery, but there is not always an obvious, real-world mechanism for implementing these innovations at scale. Just look more closely at many of the most-favored concepts of the day: covering the uninsured; accountable care entities; patient-centered medical homes; public reporting and performance measurement; pay-for-performance; health information technology for meaningful uses; reducing racial and ethnic disparities; and integrated preventive care for patients with multiple chronic conditions.
For each of these innovations, somewhere across the country � and in some cases, in many places � Medicaid is in fact already doing it.
... It is far from clear, for example, whether there would be a single national insurance exchange, or several regional ones, or 50 state-based organizations. It also is unclear whether current Medicaid and Children�s Health Insurance Program beneficiaries would need to participate in the newly-created exchange(s). Whatever administrative structure were to be developed, however, is less likely to have the experience and the institutional history of the nation�s longstanding and generally quite effective state Medicaid agencies. Health reform is too important to overlook the federalism and implementation variables, and both of these considerations point in favor of a Medicaid expansion.
... politics aside, state Medicaid programs offer important lessons and future directions for those focused on improving the quality of care, especially for high-need patients. Medicaid also offers lessons that can help to constrain costs (i.e., bending the trend) and thus make resources available for coverage expansion. Again, state Medicaid agencies are perfectly positioned for leadership in this area. For example, a number of states�Michigan, Oklahoma, and Pennsylvania�have figured out how to mine their data on the size and performance of primary care practices, beneficiary race and ethnicity, and chronic disease burden to: (a) stratify their high-volume Medicaid practices in which there are significant disparities in care; and (b) to design and support interventions to improve quality and reduce avoidable emergency room and hospital readmissions among these beneficiaries. These state pilot projects are being independently evaluated to determine whether they can generate savings that can potentially be reinvested elsewhere in the health care system.
Efforts to create integrated systems of care for the highest-need, highest-cost beneficiaries with multiple serious chronic illnesses are, perhaps, even more promising in terms of the potential for dramatic improvements. The top 5 percent of these patients account for 50 percent of Medicaid�s costs. While Medicaid is the primary insurer for this population with disabling and extremely costly chronic conditions, the same basic expenditure pattern exists in Medicare and even in employer-based insurance.
This fact has impelled leading-edge health plans like Kaiser Permanente and Aetna/Schaller Anderson to invest in Medicaid-based demonstrations to, for instance, integrate physical and behavioral health care for those with serious mental illnesses. These plans are also supporting pilot efforts to integrate care for those with numerous chronic conditions who have multiple physicians and complex health care needs, yet no accountable care management entity. That should sound familiar, in fact, very similar to fee-for-service Medicare.
That should be enough to whet the appetite for readers interested in going further. Here again is a link to Health Affairs Blog.
Stephen A. Somers, Ph.D., is the president and chief executive officer of the Center for Health Care Strategies (CHCS), which he founded in 1995 with a major grant on Medicaid managed care from the Robert Wood Johnson Foundation. In that role, he is responsible for the organization's growth into a nationally recognized center on improving care for beneficiaries of this country's publicly financed health care programs, particularly those with chronic illnesses and disabilities and those experiencing racial and ethnic disparities in care.
Michael S. Sparer is a Professor of Health Policy at the Joseph L. Mailman School of Public Health at Columbia University. Professor Sparer is the editor of the Journal of Health Politics, Policy and Law, and the author of Medicaid and the Limits of State Health Reform, as well as numerous articles and book chapters. In his writings, Sparer examines the politics of the American health care system, with a particular emphasis on the health insurance and health delivery programs for low-income populations. .
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