Playing with lives (Healthy PA edition)

I need to call out some commenters from my previous thread on the Healthy PA waiver approval.


but I thought HHS shoulda just waited until after November.

I think you are wrong for multiple reasons here.  The first, is purely mechanical.  My old team (the insurance plumbers) gamed, over a long database modification weekend, what it would take (from our perspective) to set up a private option style system in our state.  We figured that to do it right (ie actually being able to enroll people, get the docs on board, and pay a claim the first week that we received it), we would want a six month heads-up, and could do it in three or four months with lots of coffee.  Seven weeks from the first day of claims payment eligibility and three weeks to enrollment after the final approval is either impossible or a fiasco in the making.  Proposing a blatantly political stunt means people needlessly are uncovered for an extra month or two.

Secondly, I think this type of stunt is subverting the democratic process.  Our system is designed for political actors to grab a popular chunk of the other guy’s platform/policy, tweak it slightly, relabel it and claim it as their own.  Corbett is engaged in simple politics that he is trying to neutralize his opponent’s popular policy plank by stealing as much of it as he can get away with.  This is normal, mostly rational give and take transactional politics in a high veto point system.  It is healthy.

Finally, Democrats and liberals are the ones who make the argument that government can and should work.  Deliberately making the government not work in an efficient manner is not a good idea.


I don’t think it is such good news. It is not as good as just straight medicaid, and It sets a starting bargaining position for the remaining states who have not yet allowed medicare. In the short run it enrolls more people, in the long run less people at greater expense to them and to the system.

Agreed, in a universe where the Supreme Court did not gut Medicaid expansion, this is distinctly second best.  We are not on that strand of the multiverse. I think your second argument that the Pennsylvania waiver approval weakens federal  bargaining position is a non-sequitor.  The Feds, at this point, are bargaining with states’ political actors who are not too enthused or committed to expansion.  The Feds want to make a deal, the state actors would not mind doing so, but don’t have to.  The party that can more easily walk away has the leverage irregardless without regard to what other parties agree to or not.  The Pennsylvania agreement may set some limits on what non-medical restrictions can be introduced into Medicaid waivers, but that merely limits hold-out states from asking for the moon.  It is minimally relevant for other hold-out states like Wyoming from asking for and getting private option like approval from CMS in the future.

The relevant comparison for Healthy PA is what is the next likely alternative.  Is it straight up Medicaid expansion (which from a plumbing POV should be simple and straightforward), or is it nothing?  In my opinion, no expansion is far more likely than straightforward expansion as the next preferred alternative.  And that will remain the case as long as the Teabaggers control at least one veto point in the state government. They are likely to hold at least one veto point for the rest of this decade.

So again, the question is no coverage for half a million people or pretty decent but sub-optimal coverage for half a million people and the creation of some very powerful stakeholders who will make sure expansion stays in place?  Anyways, Pennsylvania has been a Medicaid managed care state for years now, and the private option/premium support model had already been approved for other states, so it is not much of a precedent.  The shocker would have been full approval without restriction of the original waiver application or full denial, not a deal.

I think the basic question is a moral question that informs our policy judgement — what policy changes are severe enough to justify not covering a quarter million people in year one and half a million people in the out years?  In my opinion, mild inefficiency through skimming and sub-optimal but still pretty good benefit design does not even come close to raising that question.

11 replies
  1. 1
    some guy says:

    the handl\se don’t work cuz the Vandals Took the Handels

  2. 2
  3. 3
    Marc says:

    You were doing so well until “irregardless.”

  4. 4
    geg6 says:

    And none of this will help him with voters. Medicaid eligibles already hated the guy and so do about 70% of us Keystone Staters. It’s a Hail Mary that’s doomed to fail electorally.

  5. 5
    brantl says:

    “irregardless”, IS NOT A WORD, DAMMIT!

  6. 6
    Paul W. says:

    I don’t care if you had left irregardless in the writeup, whether it is a “word” or not is just up to common usage. No language is static, unless it’s French. Some people mistakenly think that “y’all” isn’t a word, but they are so very, very wrong.

    As to the actual content, Hell’s yeah! I especially agree with your point that we need to get the country back into the normal form of politics: giving in to your opponents good ideas or risk getting defeated by them. No compromise politics just ends up hurting you in the end.

  7. 7
    rikyrah says:

    i knew you disagreed with me, but I’m just for straight Medicaid expansion.

  8. 8
    BubbaDave says:

    So is Richard. But even with Corbett consigned to the dust heap of history, as long as the PA legislature is being teabagged then a straight-up Medicaid expansion ain’t in the cards. So do we take what we can get, or do we leave the working poor of PA to suck it while we wait for sanity in all branches of state government?

  9. 9
    Ruckus says:

    I was against the ACA, hoping for something much better. But in the end, as I knew it would be, the ACA is far, far better than the previous clusterfuck that we had. Is it a failed system? No. Is it perfect? No. Is the PA Medicare system perfect? No. Is this much better? Yes it is. Yes it’s shitty politics but that’s the reality of our country and especially the 7 yr olds running one of them.

  10. 10
    patrick II says:

    @ Richard

    I think your second argument that the Pennsylvania waiver approval weakens federal bargaining position is a non-sequitor.

    I may be wrong on the facts, but it is not a total non-sequitor (illogical, unrelated conclusion) to say that in a negotiation, once you lower the price it will be the basis for the next negotiation.

    As for your thought that this deal will somehow make Mississippi or Alabama come more quickly to Obamacare, I doubt it. They will let the people of their state die until they have to come to a deal politically, as has happened in Pennsylvania. As Obamacare succeeds, and the success becomes more clear, program expansion will be more and more difficult to hold back from, and the drving forces for that to happen will not change much because of Pennsylvania, but because of the success of the program, the free money associated with the program, and the closing of hospitals and clinics in states that turn down the program, and the political jeopardy that is now starting to show itself in the polls of non accepting states that will only get worse for them as they become more isolated holdouts from decency.

  11. 11
    J R in WV says:


    I love your insurance series in all ways. I’m learning about something complicated from someone who knows a lot about it from working with it all day every day for years. I never knew much about the technical bits of putting real insurance policies together.

    I don’t comment on your pieces much because I have no technical insurance contributions to make. But now, today, this morning, I do.

    The sentence “So again, the question is no coverage for half a million people or pretty decent but sub-optimal coverage for half a million people and the creation of some very powerful stakeholders who will make sure expansion stays in place? ” is not a question, even though you use the word question in it, so you want a period, not a question mark. You could add “which is better,” after the word question, and them remove the extra “is”), and still use the question mark, but making the punctuation correct would be better.

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