When Is Tinkering with Safety Net Programs Harmful to Beneficiaries?, National Bureau of Economic Research, July 2021, by Jeffrey Clemens & Michael J. Wither

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Abstract

Interactions between redistributive policies can confront low-income households with complicated choices. We study one such interaction, namely the relationship between Medicaid eligibility thresholds and the minimum wage. A minimum wage increase reduces the number of hours a low-skilled individual can work while retaining Medicaid eligibility. We show that the empirical and welfare implications of this interaction can depend crucially on the relevance of labor market frictions. Absent frictions, affected workers may maintain Medicaid eligibility through small reductions in hours of work. With frictions, affected workers may lose Medicaid eligibility unless they leave their initial job. Empirically, we find that workers facing this scenario became less likely to participate in Medicaid, less likely to work, and more likely to spend time looking for new jobs, including search while employed. The observed outcomes suggest that low-skilled workers face substantial labor market frictions. Because adjustment is costly, tinkering with safety net program parameters that determine the location of program eligibility notches can be harmful to beneficiaries.

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Comment:

By Don McCanne. M.D.

Who should be deprived of health care? Likely most would agree that nobody should, and, ideally, everyone should agree.

With our dysfunctional, fragmented system of financing health care, a special funding program must exist to cover those who do not have the resources to pay for health care, thus we established Medicaid. But what threshold do we establish for eligibility? Is it all-or-none financing? Does minor tinkering invoke all-or-none decisions?

In the real-world example presented, an increase in minimum wage reduced the number of hours that a low-skilled worker could work and still maintain eligibility for Medicaid. The result was both less employment and less Medicaid. Such all-or-none decisions could be disastrous for the health care or income of an affected low-wage worker. Last year, evidence from Arkansas showed that a work requirement decreased Medicaid enrollment without increasing work.

Suppose we had a single payer Medicare for All system. Everyone would automatically have financial barriers removed from medical care. There would be no need to establish a special medical welfare program such as Medicaid. Controlling costs for the indigent would be accomplished by funding the entire system though progressive taxes. That way, everyone could have health care in a system that is affordable for each of us. The complexity and injustices of segregating patients into a Medicaid program would no longer be necessary.

http://healthjusticemonitor.org…

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Democrats Have An Historic Opportunity To Advance FDR’s Vision For Universal, Guaranteed Health Care, Common Dreams, July 14, 2021, by Nancy Altman

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FDR, his Labor Secretary Frances Perkins, and their allies had a much broader definition of Social Security than the one we use today. They understood the term as a synonym for economic security. They knew that to ensure economic security, all of us need the assurance that if faced with an illness, we or our loved ones will receive high-quality treatment as a guaranteed right.

They understood that to be economically secure, all of us must have universal, guaranteed health care as our birthright. Today’s Democrats appropriately proclaim that health care should be a right, not a privilege. Now is the moment to walk the walk, to add action to the rhetoric. …

Democrats have the opportunity to pass a package that takes the next big step in that direction. The following Medicare and Medicaid improvements are being debated as you read these words:

1. Creating an out-of-pocket cap in Medicare, because no one should go bankrupt trying to pay for health care.
2. Adding the essential benefits of vision, hearing, and dental care to Medicare.
3. Lowering the Medicare eligibility age to 60, as Medicare’s architects anticipated and as President Biden promised in his campaign.
4. Empowering Medicare to negotiate lower prescription drug prices not just for seniors and people with disabilities but for everyone in America.
5. Allowing people to remain in their homes, rather than forced into institutions, by funding home and community-based long-term care.

Each of these steps would make Americans more economically secure, and enormously improve our lives. It exemplifies the promise to build back better.

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Comment:

By Eagan Kemp

Nancy Altman, the President of Social Security Works–a staunch ally in the fight for Medicare for All–highlights how crucially important it is for Congress to improve and expand Medicare, while also lowering the cost of prescription drugs and improving access to home and community based long-term care in the next reconciliation package.

While these steps are important on their own, they also help us think about how we move from the fragmented health care system we have now to the health care system we truly need, Medicare for All.

The reality is that most people are fed up with the health care system and are ready for things to change. The question is then how do we change it.

Given the limitations of the current Congress and President Biden’s opposition to Medicare for All, how do we make progress on health care without making the situation worse?

Taking steps to reduce corporate power in health care while strengthening public programs is a good place to start. While these reforms aren’t perfect, they help us push back on the corporate onslaughts on Medicare and, if crafted correctly, will also take a bite out of prescription drugmakers’ power.

Getting these reforms over the finish line will mean relief for millions of Americans but will still take a lot of work, as corporate lobbyists fight to water them down.

But make no mistake, the fight for Medicare for All must continue, regardless of whether these interim measures pass. It will take the largest grassroots mobilization in decades to finally guarantee health care for everyone in the U.S.

Luckily, those fighting for Medicare for All haven’t lost focus. Over 20 municipalities passed Medicare for All Resolutions in recent months and many more are working to do so soon. Additionally, the Medicare for All bill in the House just added its 118th cosponsor, highlighting the progress that we continue to make in Congress. And with hearings on Medicare for All forthcoming in both the House and Senate, the support within Congress will continue to deepen.

http://healthjusticemonitor.org…

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When It Comes to People Like My Daughter, One Size Does Not Fit All, New York Times, July 4, 2021, by David Axelrod

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I am profoundly grateful for the disability rights movement that has waged a decades-long battle to shutter such institutions, many of which were run by the states, and to win for people with intellectual disabilities the right to live in small apartments and homes with services in residential neighborhoods.

But now the ideal has hardened into dogma: All larger communities are bad. All small, neighborhood-based group homes are good.

Of course, neither of these things is true, and the rigidity of that thinking denies the simple truths that there are good and bad places, large and small, and people with disabilities are not all the same. Like anyone else, they have different personalities, capacities and preferences.”

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Comment:

By Allison K. Hoffman, J.D.

I was touched by this op-ed by David Axelrod and his ability to illustrate pointedly why we need various options to meet the range of possible care needs of people with disabilities of all ages, through a telling of his own struggles to find the right support for his daughter, Lauren, who has suffered from debilitating and disabling seizures for decades.

As I discussed in my last post, Medicaid’s pendulum has swung from favoring long-term care in institutional settings to spending a majority of long-term care dollars in home-based settings. Underfunding care in home-based settings has increased reliance on friend and family as informal caregivers and as financiers of their loved-ones care (whether through dollars spent or hours spent and lost opportunities).

With the problems COVID-19 highlighted in congregate care settings, like nursing homes, some have doubled down on calls for shifting care home and dismantling care institutions, rather than making them better. Axelrod talks about a similar push that began during the mid-20^th Century deinstitutionalization movement. What he does not note is that during that movement, some families who were unable to care for loved ones with disabilities at home abandoned the legal efforts when they realized that the end goal of the litigation was to shut down institutions, not to improve them. Elsewhere, I’ve advocated for why in this moment we need to keep nursing homes, other congregate care facilities, and larger living communities, and make them better.

One part of this effort is regulatory. Another is funding. A final one is designing flexible policies, what I’ve called a policy toggle. Public financing for long-term services and supports should be designed so that people can get care at home, when it makes sense for them and their loved ones. When it doesn’t, like in the case of Lauren Axelrod, they should have the option of care in high-quality and affordable community-based settings. Too often policies have been designed with a bias in one direction or another, rather than letting people who need care, in conjunction with their loved ones, figure out the right direction so that everyone can thrive.

http://healthjusticemonitor.org…

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Comment:

By Jim Kahn, M.D., M.P.H.

Medicare offers enrollees a choice of “traditional” Medicare (government-administered coverage for virtually all physicians and hospitals in the US) or Medicare Advantage (private insurance plans with restricted provider panels). Nearly 60% of enrollees select traditional Medicare, and financial analyses by CMS, MedPAC, and others consistently show that traditional Medicare is less costly than Medicare Advantage.

However, in 2020, the Trump Administration launched a new CMS experiment, the Global Professional Direct Contracting (GPDC) model, that is designed to privatize traditional Medicare. That’s right, end the public part of Medicare as we know it.

GPDC transfers cost and care management to private for-profit insurer and investor contracting entities. Under this model, CMS could auto-assign more than 30 million beneficiaries who have chosen traditional Medicareinto entities managed by private for-profit companies, without their understanding or consent. These entities are similar to Medicare Advantage plans even though the enrollees explicitly rejected this type of coverage. Although not technically permissible, contracting entities could shift enrollees to Medicare Advantage.

The direct contracting experiment, as designed, has four profound flaws:

• Violates the spirit and public insurance essence of traditional Medicare.
• Undoes the fundamental choice made by Medicare enrollees.
• Will increase costs.
• Likely will not improve quality or allow for objective quality assessment, based on the Medicare Advantage experience.

You’ll notice that this post includes no document link at the top. That’s because this program is happening behind closed doors, on the sly. No public discussion of a massive transformation of traditional Medicare. I know about it because of the excellent sleuthing of colleagues, who have assembled a compelling analysis and report. This will be public soon, but we agreed that there is great urgency to let people know about this threat, so they can speak against it.

Here’s the solution:

1. Immediately suspend GPDC, pending full review and revision, including participation by relevant stakeholders and external experts.
2. Restrict direct contracting to entities that are >75% owned by providers, not investors or insurers.
3. Limit GPDC to < 500,000 participants.
4. Traditional Medicare enrollees must be:
   • assured full understanding of the program;
   • enrolled only if they actively “opt in;” and,
   • properly informed of their ongoing right to see out-of-network providers and to opt out of GPDC.
5. Participating providers must submit all medical claims to CMS to permit effective evaluation of cost (to CMS and enrollees), access to care, and health outcomes.
6. CMS must end GPDC if, overall, it fails to lower costs and improve the care experience within three years.

The integrity of Medicare is at stake.

http://healthjusticemonitor.org…

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