At a time when Texas officials are talking about trimming the state’s budget to deal with serious revenue shortfalls, one medical organization is instead pushing the state to expand Medicaid, via the Affordable Care Act.
But that’s the wrong prescription for what ails America’s health care safety net for the poor. Instead of expanding Medicaid’s reach, let’s broaden its scope. Let’s revamp Medicaid to make it serve those it covers now more effectively, allowing innovation and new approaches. We can still ensure that the net is there even for those with pre-existing conditions by establishing guaranteed coverage pools.
In other words, let’s give Americans more choices—not fewer.
We must begin with a better understanding of the uninsured. The fact is that most of our nation’s 28.3 million uninsured qualify for some kind of assistance already—yet they do not take advantage of it. According to the Kaiser Family Foundation, 57 percent of the uninsured in 2018 were eligible for financial assistance through Medicaid or marketplace subsidies. Why didn’t they participate? A plurality (45 percent) say the cost of premiums is too high—something the ACA promised to address, but failed.
Another 4 million are ineligible due to their immigration status (something Medicaid expansion wouldn’t address, either). In fact, only 8 percent of the uninsured (2.3 million total) are in the coverage gap—they truly can’t afford insurance but don’t qualify for government assistance. That’s less than 1 percent of our population.
It simply doesn’t make sense to expand a massive, cumbersome and deeply flawed Medicaid program to cover that additional 1 percent. More targeted assistance, and a nimbler, more effective Medicaid system overall would have a far greater impact on public health—and our fiscal well-being.
What does make sense is to improve Medicaid and its delivery of care to those it already serves. Currently, Medicaid recipients are finding that coverage doesn’t equal care. Dismally low reimbursement rates mean that doctors are less likely to accept new Medicaid patients (sending more and more to emergency rooms with primary care complaints, or leading them to delay care).
But what if we allowed Medicaid dollars to be used differently? Medicaid funding could easily cover Direct Primary Care arrangements for many recipients. In DPC, patients pay physicians a subscription fee (often less than $80 per month) that covers most of the primary care and urgent care we all need. Using innovative technology such as HIPAA-compliant smartphone apps, patients can build the kind of effective relationships with their doctors they could never have in an ER setting. Many physicians report they’re able to treat long-term issues such as diabetes more effectively with that strengthened doctor/patient relationship.
Other innovations, such as direct doctor-to-patient medication delivery (which better ensures prescription compliance), broader use of telemedicine and incentivizing Federally Qualified Health Centers to care for our rural communities, could remake Medicaid into a more effective program to help the nation’s poor.
When combined with guaranteed-coverage pools for those with high-cost health needs, we can make real improvements in the health and well-being of Americans.
Don’t let the COVID-19 pandemic drive Medicaid expansion. The states hardest hit by the coronavirus are states that did expand Medicaid, including New York, New Jersey, Washington and California. Medicaid expansion is no panacea for this or any other pandemic.
The problem with Medicaid isn’t that it’s not big enough—it’s a regulatory behemoth. And it’s not that the program doesn’t cover enough people—it already covers 65.6 million Americans (with another 6.7 million more enrolled in the related Children’s Health Insurance Program).
The problem is that it doesn’t work very well for those for whom the program was intended.
We can improve Medicaid and help ensure that the most vulnerable among us receive the care they need. But we do that by reforming Medicaid and allowing Americans more choices, not by simply expanding a program that isn’t meeting their needs.