Tom Wilemon’s great Medicaid coverage for The Tennessean—including his report last week that Tennessee’s Medicaid budget could be cut by $400 million—got me thinking about other states, and other reporters who’ve tried to get their arms around this beast of a story. What’s the Medicaid story going forward? How do we move beyond the now-familiar story of conservative politicians saying “no” to expansion of the program, while capturing the significance of other state-level policy decisions?
To get a handle on some of the Medicaid issues that may surface in 2015, I called Alan Weil, editor-in-chief of Health Affairs, a leading health policy journal. Weil knows Medicaid well: Until recently he served as executive director of the National Academy for State Health Policy, and he ran Colorado’s Medicaid program in the 1990s. What follows is an edited transcript of our conversation.
What’s likely to be Medicaid Topic A in the upcoming national debate?
We know from the past the preferred Republican approach is to convert the program to a block grant. Medicaid is currently an open-ended matching program: The more the state spends, the more federal funds it receives. The way a block grant works is that funding levels are determined in advance. To save money, which is an important federal goal, the funding formula has slower growth than what you would expect if you had kept the program as it is.
During the Clinton administration some Democrats proposed what they called a per-capita cap. Under this plan, a state could receive more federal dollars for enrolling more people but there would limits on what they could spend per person. This, too, would have the effect of lowering federal spending.
Do these options have legs this year?
New governors come in with thoughts about Medicaid but learn it’s a really complicated program. Rhetorically the block grant option is appealing to many governors, but it is hard to know yet if they will be a strong voice in support of that option. No one expects Obama will sign anything resembling a block grant approach. A lot will be proposed to set the stage for future discussion.
The Obama administration has a great deal of discretion in how it runs Medicaid at the federal level. How might that play out?
We have an administration facing a Congress controlled by the other party, and they face a challenge on any topic. On Medicaid, do they use their discretion to accommodate requests from the states, which will relieve pressure for more fundamental change? Or do they hold tight to the existing program, worrying that giving states big waivers will set the stage for more fundamental legislative change in the future? It is a difficult strategic choice for the administration.
One of the challenges for reporters will be understanding how to decode the talk from politicians. What can you suggest for better coverage? What are the buzz words—the language—reporters will hear?
The past is prologue. We’ve heard this before, but reporters need to be aware of the terms that will frame the discussion. On the Republican side you’ll hear the words flexibility, local control, and personal responsibility. The Democrats will talk about helping the neediest, a national commitment to the most vulnerable, and Medicaid is there when you need it. Both sides are looking for words that resonate.
Reporters need to know those words don’t necessarily mean the policies [politicians] propose are the best embodiment of those words. Flexibility is a value, but the question is what are you going to do with it. Flexibility doesn’t save money and doesn’t improve care, but it may let you do those things. The question reporters need to ask is, ‘flexibility to do what?’
And on the other side, when people talk about protecting the most needy, ask what ideas they have for improving the program. What changes are you open to, and how would you pay for the programs you are advocating?
Any additional advice for journalists who will cover this issue in their statehouses?
Ask a lot of questions. If the Medicaid expansion is being discussed, look at the people side and how it affects hospitals and businesses. Get beyond the political rhetoric.
There’s been talk over the years about whether Medicaid is a revenue-sharing program for the states or a health program for the poor. Which is it?
It’s a widely held view that states game the program. The idea that some states try to maximize their federal revenues is a true statement. But for all the attention that line of thinking gets, the vast majority of the dollars go to pay for health services for poor people. I don’t minimize the degree of fiscal gaming, but there’s a long way between playing at the margin and being a general revenue program.
What’s likely to happen with CHIP (the Children’s Health Insurance Program) next year?
The federal government must act by next September before current funding expires. The program has bipartisan support, but these days everything is controversial.
One issue that’s been around since the Affordable Care Act passed is do we want to keep families together insurance-wise. That is, should families be on the same plan because it’s easier for families to navigate one program? On the other hand, CHIP is targeted at kids and some elements of it offer more protection than what’s available in health insurance plans sold on the exchanges. If you move them from CHIP, there will be larger copays and cost sharing which may make it harder for parents to take their kids to the doctor. Both Medicaid and CHIP have a lot of elements that support kids such as comprehensive benefits and strict limits on how much you can charge families to take their kids to the doctor. The Affordable Care Act provides comprehensive insurance coverage but doesn’t provide the same level of protection. These are competing values.
So it’s a trade-off between keeping families on the same insurance plan and the potential for better healthcare for kids. How do reporters bring out this trade-off?
The best way is to look at the experience of a specific family. Compare what they pay under the different rules. The contrast is pretty stark.
Do we know whether the Medicaid expansion programs in the few states that require recipients to have more “skin in the game” are working?
I don’t think I can answer that in a generic way. These programs have different goals and I always think if you are going to ask if something is working you have to start with what the program is trying to do. One key metric is whether people are getting necessary care, but these programs have to be around long enough to find out, and they haven’t been.
How far will these alternative programs evolve?
The Medicaid protections are still intact. Some states are charging modest premiums, and there may be a health savings account. But they can’t charge the kind of deductibles you see in the exchanges. No one on Medicaid is being charged deductibles like that.
What’s the next step here? Are states going to try to put more Medicaid recipients in the exchanges?
There’s already interest in this and reporters have to be aware of the nomenclature surrounding this. Arkansas led the way and a handful of other states have approaches that build from what they did. They key language is around privatizing Medicaid—the notion that it’s better for people to be in private insurance than in a government program. Of course in almost all states the vast majority of Medicaid enrollees are already in private plans. It’s just that their premiums are paid by the government.
Medicaid managed care has come to many states now. Do we know if it has saved money for states and provided better care, which was one of its promises?
The overall track record for Medicaid managed care is pretty good. After some false starts a few decades ago, states now know how to hold managed care plans accountable, and those plans can fix some of the problems with the regular Medicaid program. The current wave is relying upon managed care for people with much more complex health and social needs. This shift has been rapid, and is fairly recent, so it is much harder to draw conclusions about its effects.
What are some questions and sources reporters can use in reporting on this?
I always return to looking at the program through the lens of the individual or family. Medicaid is so complex and involves so much money that it is easy to get lost. But, fundamentally, it is a program designed to meet the health needs of very vulnerable people. If that’s the goal, then stories should start and end with the question of whether or not the program is meeting that goal.
Related content:
The Tennessean pushes for better healthcare
Michigan’s Medicaid program is going to be great, say Michigan Medicaid officials
What’s missing from Medicaid coverage: actual people
Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.