Medicaid buy-in support

Friend of the blog, Emma Sandoe and other researchers in Boston, ran a poll on Medicare for All and Medicaid Buy-in programs.

The results are interesting on several metrics:

Medicare for All has about 36% support and 38% opposition. That is a steep hill to climb to build a majority coalition.

Medicaid Buy-in has a majority in at least tepid support and very little passionate opposition.

This is interesting on several levels.

The first is that Medicaid’s branding seems to be stronger than Medicare’s branding.

Secondly, Medicaid buy-in is much easier to implement in at least some states. Right now New Mexico is aggressively pursuing a buy-in investigation. I think Nevada may be tempted to go down that path. Implementation requires a state to be in favor of a buy-in program and a friendly reading of waiver authority from the Center for Medicare and Medicaid Services (CMS). That duality may not be satisifed at the moment but a friendly to this type of waiver CMS is an easier lift than a Medicare for All friendly trifecta.

Medicaid buy-in programs are envisioned as supplements or complements to the Exchange/Marketplace structure. Emma and I looked at the different evaluation questions that need to be asked about these programs last March in Health Affairs:

There are two different policies that can be described as Medicaid buy-in programs. The first would be creating a new eligibility category for direct purchase of Medicaid by individuals with all of the attendant rights, obligations, and services that flow through Medicaid. This version of Medicaid buy-in requires modifications to state plan amendments and likely will require an 1115 waiver. The other policy would be to use the framework of Medicaid managed care contracts and networks to create metal plans for purchase on the Marketplace. Policy makers must identify which type of Medicaid buy-in they intend to use to communicate clearly their goals and objectives. Below, we present the various goals that policy makers may seek to achieve with Medicaid buy-in programs and how these goals should be evaluated…

  • Improve Coverage For The Current Individual Market
  • Provide Options For People Living In Regions With Limited Choices Of Health Plans 
  • Improve The Viability Of The Private Insurance Marketplace
  • Reduce Premiums For Consumers In The Private Insurance Market
  • To Provide People With A Guarantee Of Coverage With State-Mandated Consumer Protections
  • Improve The Financial Viability And Contracting Power Of The Medicaid Agency

A well-designed Medicaid buy-in program won’t achieve all of these goals. It may only intend to achieve one or two of these goals.

I think that Medicaid buy-in is one area of promising state-level experimentation that has a reasonable chance of implementation before 2023. The fact that there is a broad base of support and little concentrated opposition merely increases the probability of state level experimentation. This is where the action will be over the next couple of years for states, politicians, and activists that want to continue to expand coverage.

Preparing for 2021

New Mexico is preparing for an ambitious future for health policy. Louise Norris notes that New Mexico is looking to move off of and open up their own state based exchange.

In order to reduce user fees, the exchange board considered the issue during a September 2018 board meeting, and voted unanimously to transition to a fully state-run exchange in time for the 2021 plan year.

The exchange will put out a request for proposals in early 2019, as they work to find a vendor to create their state-run enrollment platform. The system will be live by the fall of 2020, in time for the open enrollment period for 2021 coverage (November-December 2020).

There are two good reasons to go down this path. The first is the obvious one: it’s cheaper than using charges 3.5% of premium as an Exchange fee for states that don’t do anything on their own, and a 3.0% of premium Exchange fee for states that manage significant elements of the enrollment process. New Mexico is one of the “partnership” states that uses the front-end but manages a lot of their own back-end. 3.0% of premium is not a good deal. The same fee level would either be used to fund significantly more outreach, advertising and navigators or the same level of outreach and support that provides could be funded at a much lower fee which would slightly reduce baseline premiums.

Secondly, New Mexico is getting ambitious. They are the leading innovators in doing the actual hard work of figuring out how a Medicaid buy-in proposal. This would be effectively a state based public option. This would be a major rejiggering of the New Mexico individual market.

The Center for Medicare and Medicaid Services (CMS) has repeatedly stated under both the Obama and the Trump administrations that they can’t do much with the back-end of to support unusual or aggressive waiver requests. If New Mexico moves towards a Medicaid buy-in model, their open enrollment, subsidy structure and eligibility structures would be unique. The only way that can work within an Exchange framework is if New Mexico can customize the exchange that their citizens and residents see.

So, this is both an effort to reduce premiums through either attracting a healthier risk pool or lower costs of attracting the current risk pool AND a necessary step in building the infrastructure to support a Medicaid buy-in program.

Purdue Pharma and the Justice Department Knew About Oxycontin in 2006

Purdue Pharma knew the dangers that Oxycontin presented, and so did the Justice Department, as early as 2006. But the George W. Bush Justice Department decided not to prosecute.

Based on their findings after a four-year investigation, [federal] prosecutors recommended that three top Purdue Pharma executives be indicted on felony charges, including conspiracy to defraud the United States, that could have sent the men to prison if convicted.

But top Justice Department officials in the George W. Bush administration did not support the move, said four lawyers who took part in those discussions or were briefed about them. Instead, the government settled the case in 2007.

Of course, current Purdue Pharma officials play down that something a decade ago could have anything to do with today’s opioid crisis.

“It would have been a turning point,” said Terrance Woodworth, a former Drug Enforcement Administration official who investigated Purdue Pharma in the early 2000s. “It would have sent a message to the entire drug industry.”

The Sackler family, who have endowed many museums, have been intimately involved in Purdue Pharma from the start. I’ll never feel the same about those museums.

A spokesman for Sackler family members involved with the company, Linden Zakula, declined to comment. Richard Sackler, who is now a director of Purdue Pharma, also declined to comment.

There were plenty of warnings. The article has much more detail – a long read. It’s the New York Times, but one of the places where they’ve done a good job.

And open thread!

The Mystery Man Revealed – And Open Thread

Quinta Jurecic and Ben Wittes have written their article on outing FBI informants, and several outlets have given the name of the probable informant.

I have the sense that I still don’t fully understand this situation, which I commonly get about revelations of the Trump campaign and its connections to various skeevy people. That is probably because there are more shoes to drop from this centipede, so I can’t fully understand the situation.

That Stefan Halper might be an informant has been publicly discussed since March. His positions and connections should have suggested that possibility to anyone who dealt with him before that. The Washington Post and New York Times articles of Friday night, together with material published earlier, lead to the conclusion that the person being discussed is Stefan Halper.

What Halper did was talk to George Papadopoulos and propose a project with him and also met with Carter Page and Sam Clovis in the summer of 2016. Earlier he met with Michael Flynn. Presumably this was because the FBI had information that Russians were communicating with these folks, and Halper was trying to get information about how that was going down.

The FBI could have sent agents openly to talk to those people, but they probably decided to take an indirect route because of the proximity of the election. Those FBI visits would have gotten out and caused some publicity. This is one of the asymmetries with how the Clinton emails were dealt with.

It would have been good practice for the Trumpies to have notified the FBI themselves when they were contacted by Russians, but, as we have seen in other cases, they did not once see fit to do this.

Since Halper already had a public profile and connections to intelligence agencies, it’s not clear to me why outing him seems to have been such a big deal to those agencies, who were reported to have been working for weeks to minimize the damage if he was outed. It’s possible that he was doing more than what is publicly available, and that those additional activities were much more sensitive.

Part of the concern is that if Congress is willing to reveal intelligence operatives for political reasons, it will be much more difficult to recruit sources and informants. And, of course, the President has now piled on.

It’s not at all clear why Devin Nunes, Trump, and others claim that knowing who this person is will undercut the Mueller investigation. They have claimed a connection between him and the Steele dossier, but, if anything, the information Halper obtained would have gone to the FBI before the dossier did. So, to the extent Halper’s material correlates with what’s in the dossier, it would be independent support.

It’s also not clear how all the information was leaked. Did the leaks start in March? Who are the sources for the Times and the Post stories? Will this be prosecuted the way Valerie Plame’s outing was?

The Jurecic – Wittes article is long and much more closely argued than what I’ve written. Very worth reading.

Schadenfreude. It’s what’s for breakfast*

Which is to say that there are few people in American politics I loathe so much as the wholly owned Koch subsidiary operating under the name Scott Walker.  There are plenty of folks doing more national damage, but few, if any, with the utter, total, almost heroic lack of redeeming qualities as the man Charlie Pierce epithets** as the goggle-eyed homunculus.

So his pain is the sugar in my coffee this a.m.:

“The Far Left” — thanks for the proper nouning** there, btw; I didn’t know we were a franchise operation — as in a decisive majority of Wisconsin voters. “Anger and hatred” — nothing like the mild mannered folks on the right,*** amirite? “Outside special interest money.” Child, please.

But, if it’s all projection with these guys, well we knew that. That subterranean pleasure you feel this morning is that all the faffing in the world can’t hide the genuine panic flowing through Walker like you-know-what through a goose.

And because we need something pretty to wash the memory of Walker’s pallid, grasping mug from our brains, here’s a bird that one-ups that poor goose:

And w/that…open thread.

*That or coke on your Wheaties.

**I verb sometimes. Sue me.

***Very, VERY far from the worst, as we all know, but selected for its exceptional combination of absurdity and cowardice.

Image: John James Audubon, Cygnus buccinator, Trumpeter Swan1838.

Utah’s partial expansion request

Utah’s governor just signed a bill that authorizes a 1115 Medicaid demonstration waiver. The waiver combines work requirements with a request. This is interesting on several levesl.

KUER reports:

The new law would ask the federal government to allow Utah to widen it’s low-income health insurance program. Right now, a single adult with Medicaid coverage can only make about $600 per year — essentially homeless. Under the new law, the same individual could be covered if they make anything up to the poverty level, approximately $12,000 per year.

It also adds a work requirement for those who qualify. If an individual is unemployed and wants Medicaid coverage, they’ll have to do things like get job training, volunteer or take classes.

This is interesting on several levels. First it is a red state with a Republican trifecta trying to expand Medicaid. They are asking for a work requirement but as far as I can tell the requirement would only apply to the expansion population. This is still a lot of people who make very little money so the vagaries of scheduling and intermittent work will be a massive implementation challenge but the work requirement is less restrictive than several that have been requested.

Far more interesting to me is that Utah is asking for a partial expansion. We’ve talked about partial expansions before.

The distributional consequences are important. For people who earn between 100-138% FPL in states that have not expanded Medicaid, nothing will change for them. They are no worse off. People who live on less than 100% FPL in these states will be dramatically better off as they will have Medicaid for their coverage….

More interestingly to me is that CMS recently turned down Arkansas’s request to change the enhanced match rate Medicaid expansion to 100% Federal Poverty Level (FPL) instead of the current 138% FPL. However there is a very critical difference: Arkansas had already fully expanded Medicaid. They went for the most expensive and convoluted system of expansion possible by sending most of the healthy population into the Exchange pool. That system costs 24% more than a straight up expansion of Medicaid but it got local buy-in. However Arkansas is now paying a fraction of the cost of expansion and they’ve been moving more of their private option population back into the less expensive legacy Medicaid system. The Arkansas proposal to shift the 100-138% FPL cohort to the Exchanges and off of Medicaid was an attempt to dodge previously obligated committments.

Utah has never expanded Medicaid. The 100-138% cohort is already on the Exchange and they are already eligible for federal subsidies. Expanding Medicaid to only 100% has no increase in costs for the Federal government on the Exchange side of the ledger. If there is only a partial expansion, the Feds are paying for the 100-138% cohort and if there is no expansion the Feds are still paying. This is a very different fact pattern than Arkansas so there is a chance that CMS could approve the waiver.

And if that is the case, then several more hold-out states would probably seek the same waiver.


Update on the WV Teacher Strike

Over the weekend, there was some movement in the Senate, along with some hysterical shenanigans. Basically, WV Senate Republicans are as incompetent as national Republicans, and after an amendment came out of the Finance committee for a 4% raise, lower than the 5% the governor and teachers agreed to, and lower than the 5% the House voted 98-1 for (comically, the one no vote was Saira Blair, the young Republican college student and daughter of Senator Craig Blair, and she claims she pushed the wrong button).

Quick interlude- Craig Blair is one of those “special” Republicans, who this weekend infuriated basically everyone by reacting to this CNN story about WV teachers packing lunches for their students who go hungry without school lunch programs before going on strike by stating something to the effect of “If they can afford to feed their kids, how desperate are they for a raise.” Yeah, he’s one of THEM.

At any rate, the Senate voted on a 4% raise, which was dead in the water in the House of Delegates, and immediately after the vote Senate leadership went through a bunch of procedures to have the vote removed. Apparently the clown caucus had filed the wrong amendment, and they had all voted for a 5% increase, not the 4% they intended. Normally parliamentary procedures would dictate a 2/3 vote to remove that previous vote, but being Republicans they said to hell with it and just did party line votes and then advanced the 4% bill instead. Democracy, fuck yeah.

So where we are now is there is a legislative conference committee set to meet at 4pm to resolved the differences. The committee includes 3 members from the House of Delegates (2R, 1D) and 3 members (2R, 1D). Notably, the House delegation has all been told to stand strong and presumably will lobby for the 5% they voted for (part sticking to their initial bill, part being told by membership what to do, and part dick-measuring contest between the House and Senate. The Senate Democrat will presumably go for the 5% increase.

This would lead one to presume that the 5% increase would carry the day. They would meet, majority would vote 4-2 for the 5%, and then the bill would be advanced to the Governor. You would be wrong. The majority members of the Senate are going to be Sen. Ryan Ferns, the Senate Majority Leader, and Mitch Carmichael, the President of the Senate, the aforementioned senator Blair and they too are special kinds of Republicans. What they may do is simply refuse to sign the conference committee report. So even though the vote would be 4-2, simply refusing to sign it would basically kill it. They’re the special kind of assholes who would do something like that, and the Senate Republicans done it before, just not with this much attention focused on them.

It wouldn’t surprise me if they do this to try and drag this strike out and have AG Morrisey cook up some sort of legal action against the teachers or to try and swing popular opinion against the teachers. The problem for them is everyone knows a teacher and likes them. The same can not be said for the Senate, Justice, or AG Morrisey.

In other news, the Senate Republicans refuse to meet with Governor Justice, who is now officially hated by Republicans as much as by Democrats, and the PEIA commission is set to meet on the 13th and has 24 members, 23 of whom need to be appointed.

In other words, there probably isn’t going to be school this week. The teachers and service personnel have their blood up and are sick of the bullshit.

*** update ***

The House Democrats send this notice:

“It has been brought to our attention that Senator Blair scheduled a Finance Committee meeting for 3:00 today. In his speech on the floor earlier today, Senator Blair stated that the Finance Committee will take up the budget bill and they will not adjourn until they are finished, even if it takes them until MIDNIGHT! Senator Blair is on the conference committee for HB 4145, the pay raise bill, and the conference committee scheduled for 4:00 today cannot meet until Senator Blair and Senator Ferns adjourn from the 3:00 Senate Finance meeting. This is political gamesmanship at its worst. They clearly have no intention of holding the conference committee for the pay raise bill today.”