Medicaid must be abolished. But not like that! – The health care blog

By Matthew Holt

A long time ago in a different country, there was an election of landslide of a population in search of a change. And the change they obtained. The Americans have been campaigning for national health care since 1917. There had been failures in 1933 and 1946 and 1961. But in 1965, they obtained it. Sort of.

But a strange thing happened at the congress. The manufacture of political sausages came a plan that “took care” of those over 65. While another plan is out, it “helps” the poor. (Stole this at the wonderful Adimika Arthur). Even stranger, the Medicare program was and is a program funded by the federal government. The Medicaid program was a program administered by the state, even if it was funded at least half by the federals.

This meant that Medicaid was always vulnerable to the whims of states. Of course, many states had already demonstrated dismal files in the way they dealt with their poorer and minority populations in the past (think of slavery, Jim Crow, KKK, separate schools, fonts fountains, bus … you have the idea).

Thus, while Medicare became the Savior program for all those who reached 65 years, and later for those who were disabled or who had a kidney disease, Medicaid was a program for the poor who had treated badly. (Stole this at Jonathan Cohn). And right now in 2025, it is still a severe threat.

Before arriving at this threat, it is worth watching the program. Medicaid has evolved and now covers most nursing home care (for the “poor” seniors), take care of the disabled and even pays the Medicare bonuses share for people too poor to pay for their own. It also covers health insurance for the poor under the age of 65 and in the states that have accepted the expansion of the Aca Medicaid, this is a considerable number. Of course, these are people under an imaginary line that makes them too poor to buy on the exchanges set up by the ACA. And generally Medicaid includes the Chip program, an insurance program that covers poor children set up under Clinton in 1997.

This graph of the venerable KFF shows that if 75% of people on Medicaid are, poor, under 65, and not classified as disabled, 50% of money goes to those who are not.

All this translates into a bizarre world in which there is a program of the federal government for people more Also in the federal program. It’s completely stupid and has always been.

Of course, there is more than that.

Many states that do not share this Confederate heritage have done a lot with Medicaid. Oregon, for example, has always tried to increase the coverage and spend money on community care in a different way. The doctor and three times the Governor of Oregon, John Kitzhaber, vocal on what they did before the ACA and how Medicaid should change to reflect these new realities.

Since 2012, under an exemption 1115, Oregon Medicaid has been provided by new coordinated care organizations (CCO) – Community organizations responsible for providing quality medical care, while also focusing on community health. They operate on a global budget indexed by one member per year a growth rate lower than medical inflation. CCOs are also required to maintain inscriptions and benefits, while meeting rigorous measures around the quality, results and satisfaction of patients. Before the first period of derogation at 5 years, Oregon scored 384,000 additional people and operated in the growth rate per member per year. All CCOs respected the required quality and results measures and achieved a clear cumulative saving of $ 1.1 billion.

In fact, Oregon is by no means the only state that has done something different. California is massively extended coverage after ACA and now 15 million people or more of its population are on Medicaid. At the same time, there was a ton of experimentation within the program. These exemptions 1115, which are required to spend this federal money in an unnassed manner in the 1965 law, have done overtime in the Golden State at the level of the State and the Comté. The overview is that Medicaid here has been transformed into a more complete program called Calaim (California Advancing and Innoving Medi-Cal) which covers all kinds of things not in traditional Medicaid, including double health workers (which could also be barbers!) And in some housing and food counties.

Despite these improvements, I would not suggest to deliberately move to Oregon or California and whether you become poor. (Stole this line to my late boss in Harris, Bob Lietman)

But there is one more tonne at Medicaid on a national scale. Since the 1990s, most care has been directed to private health plans, although many have been managed publicly. But Centene and Molina particularly created very profitable cases on Medicaid in the same way as United, Humana and Al have undermined Medicare Advantage.

And although he did not speak strictly speaking via Medicaid himself, we have also built many other sources of financing for suppliers of safety nets. This includes the 340B program that hospitals use to earn money on drugs, dish payments that go to hospitals that deal more with the poor, then there are about 35 billion dollars and federal funding for FQHCs which treat many uninsured populations and Medicaid.

So we built this incredibly inflated mess with a program. It is mainly administered by organizations which are commercial or county plans which do not resemble the plans of the Americans regular employees obtain their coastal. These plans buy care from a network of facilities (FQHC, County Hospitals et al) which obtain a large part of their Medicaid money or use a lot of other ways to collect funds. And these providers’ institutions do not resemble much or do not share many customers with regular doctors and health systems where most of the Americans employed or those who have health insurance receive their care.

And you thought separately but equal was abolished in the 1950s!

Now, of course, Medicaid is under a great threat, because in some respects, the ACA is the ACA. The Trump administration, with a South African immigrant wandering with a literal and figurative chainsaw, has promised cuts. The most common number suggested is $ 880 billion over 10 years. Now it’s a big piece. $ 90 billion – the annual equivalent – represents approximately 15% of the program’s federal expenses. Of course, this is a program that spends a lot in the red states, but of course, many of these expenses in the red states are in black and brown, and many white voters of Trump do not realize that it also covers many of their white political allies. Wendell Potter and Joey Rettino stressed that, given that many states call this something different from Medicaid, it is possible that a lot of voters with low information of Trump voting on red voters may not realize that he covers them!

Despite this, a reduction of 15%, in a program that is spread out like peanut butter and already pays low costs to suppliers and nursing homes, will be a problem.

The other question concerns regulations. These omnipresent derogations 1115 allow many programs that are not in original regulations, and of course, obtain or renew a renunciation of the new HHS and CMS can be delicate. Of course, the Republicans are obsessed with assure them that anyone on Medicaid works. These “work requirements” were deployed in a few states during the last Trump administration. They ended up not saving money and were unnecessarily honest. But since the desires of the current administration are as cruel as possible, it is very likely that the ideology wins here and that the work requirements or other stupid shit can be imposed on each state.

The current fight will therefore be the DESMS in the Blue States trying to keep Medicaid as is. See how it goes and if the counterprices can keep their slim majority together when some of them realize what it means.

But that’s not what we should do with Medicaid. Instead, we have to take the plunge that the Clinton tried to take, but Obama and the ACA dodged.

We must not reform or undo Medicaid. We have to abolish it.

If instead, we must use this Medicaid money to create an appropriate universal health care system and put people on Medicaid on the same financial and delivery platform as Medicare and commercial insurance. Whether we do it in a multi-payeur world that Japanese and Germans, a version mainly of payers such as the French or Taiwanese or a nationalized system like the United Kingdom and Sweden, this would remove the status of second class health care of the ⅓ of our citizens who do not have a health insurance or good private insurance. In addition, this would allow our clinic professionals to practice medicine as they wanted when they were young and idealistic, and not to have to worry about the amount of patient, because they would get the same amount, no matter who he dealt.

Look at the political dynamics that will plead for an equal treatment for all in America, and not keep a social protection program which emerged from a political error in 1965.

Matthew Holt is the editor of ThcB