WHEN PEOPLE – including candidates for president of the United States – advance single payer Medicare for All, they speak of the desire to ensure that all Americans have health coverage, which is a worthy and achievable goal. At the same time, they cast aside some of the things that work really well about our existing system. One of them is Medicaid.
Medicaid was enacted alongside Medicare, but for decades it assumed a much lower profile than Medicare. This is due to several reasons, including the fact that Medicare is universal among seniors – everyone over 65 has coverage – and traditionally Medicaid was viewed strictly as a welfare program and, therefore, not really relevant to working Americans. This was the case even as Medicaid grew, first to cover many seniors in nursing homes and later to cover children in families above the poverty line.
Medicaid finally took its rightful place at the table as the Affordable Care Act (modeled after health reform here in Massachusetts) enabled states – which run Medicaid, sharing the expense with the federal government – to expand eligibility to cover more people, particularly families headed by lower-income, working individuals. Some states opted for expansion, taking the increased federal dollars that come with it, and others have refused.
What is so noteworthy about Medicaid is that it has become a focal point for health care policy innovation. Health care innovation can be seen to a much greater extent in state Medicaid programs than can be in the federally-run Medicare program. These state programs are also known for attracting tremendous talent to their leadership ranks. Some of the best minds in health care today are working at state Medicaid programs, or in the associations and think tanks that track these programs so closely.
In many respects, we have 50-plus (US territories have Medicaid programs, too) health care innovation labs that are cranking out some of the most exciting reforms. When Massachusetts Gov. Charlie Baker signed the state budget into law on July 31, he was also authorizing Medicaid prescription drug price reform that will enable the state to become the first in the nation to negotiate prices with drug manufacturers. What has Medicare done to lower drug prices?
Medicaid programs are also implementing health care delivery reform by creating new mechanisms for those who have been challenged in getting access to care in the past, and that is something Medicaid programs are singularly qualified to do.
We lose this innovation and don’t leverage the progress these programs have made by switching to Medicare for All.
It is Medicaid that has been the leader in addressing social determinants of health – the factors that tremendously impact health, like housing and nutrition, but are not actually health care services – by providing reimbursement for them and measuring their impact on overall health.
It is also Medicaid that has been a leader on integrating behavioral health into our health care system, such as by funding pilot programs that devise new ways to ensure that people with these needs are identified and supported, and that mental and physical health issues are each properly treated.
Rather than giving every American access to a public insurance program, there is much to be said for broadening eligibility for existing programs while leaving the private health insurance system in place. To envision how we might do this, consider the Medicaid Buy-In.
People with disabilities who are working often have a hard time affording the medical care they need because commercial policies can be limited and they may make too much to qualify for Medicaid. Some Medicaid programs let these individuals buy in to coverage. They pay a premium like they would any other insurance, and they get Medicaid coverage to supplement their private insurance.
I have had the chance to help people with a disabled child who were considering quitting their job so that they could care for their child. When these people learn of the Medicaid buy-in, an enormous weight is lifted. They are able to purchase affordable, comprehensive health care coverage.
The buy-in could be expanded to other populations. It’s a good bet it would be much less costly than the $30 trillion over 10 years that Medicare for All is projected to cost.
Like any other program, Medicaid has its share of troubles. Fraud and abuse occur just like they do elsewhere. The eligibility system is enormously complex. Rates paid to providers are often below the cost of care. Those issues shouldn’t cloud our judgment when considering the success of Medicaid.
We can expand coverage significantly without Medicare for All.
Even more important, let’s not get rid of something – Medicaid – that for the most part works really well.
Gerard A. Vitti is the founder and CEO of Healthcare Financial, Inc., a Quincy-based company that assists individuals in obtaining health care benefits.