It is way too early to break out the champagne over the
latest Medicaid expansion initiatives bubbling up around the nation.
States that have been reluctant to expand traditional
Medicaid are ablaze with proposals to offer “premium support” to expansion
populations.
Premium support programs
may differ in their details, but they have one thing in common. Instead of offering regular Medicaid to an
expansion population, the state pays the cost of their private insurance
premiums.
Kaiser
Health News reported last week that the Department of Health and Human
Services is encouraging states to explore this approach. MSN featured some “let’s
make a deal” offers on expansion by a number of GOP legislators. And Health
News Florida reported a wave of bipartisan enthusiasm for a Florida premium
support proposal that was unveiled after support for traditional Medicaid
expansion collapsed.
For policymakers who don’t like Medicaid but want the
federal expansion dollars, the benefits are clear. They can prop up the private insurance market
as an alternative. They can allow
children and parents in Medicaid-eligible families to be covered by the same
insurance. And they can make the Medicaid
program appear smaller to the naked eye.
But based on expert evaluations,
the benefits of premium support may not be so clear for today’s expansion
populations.
By the early part of the last decade, at least seventeen
states had premium support programs in some
form, according to a 2005 report of the State
Health Access Data Assistance Center.
And from the perspectives of the states running them, the
programs had some problems.
There were significant upfront costs and administrative
burdens, difficulties in enrolling families, and challenges in defining the
roles of employers. And they often had
to be supplemented by regular Medicaid, in which “wrap-around” Medicaid
benefits were offered to close the coverage gaps in traditional insurance
products.
From the perspective of potential Medicaid recipients, there
were also some significant challenges.
Writing in Health
Affairs in September 2005, Janet Mitchell, Susan Haber, and Sonja Hoover compared
the regular Medicaid program in Oregon with a premium assistance program also
offered by the state.
They found that the families enrolling in the premium
assistance program:
- Were less likely to be of Hispanic origin;
- Were more likely to have at least one parent employed;
- Had higher levels of educational attainment;
- Had better health status;
- Were more likely to have had experience with private insurance programs; and
- Were more likely to receive care in a doctor’s office, as opposed to a community health center.
We can divide today’s
expansion population into three groups – better educated parents of SCHIP
children who have a medical home and place a premium on staying well; parents
who use safety net services episodically only when they are sick; and
childless, mostly single, adults with chronic conditions.
Based on the evaluations, only the first group is clearly helped
by premium support – provided enrollment is encouraged and simplified.
The second group may be helped, but only if the states put additional
resources into education and outreach.
As the Health Affairs authors put it:
“If premium subsidy
programs are to be successful in enrolling low-income families, the results of
our study suggest that these programs may need to be accompanied by efforts to
educate these families about the importance of health insurance and how it works.”
The third group is
one for whom premium support may be no answer at all – low-income, uninsured childless adults who
have chronic conditions. Up to 6.6
million people in the Medicaid expansion population have mental illnesses or
addiction disorders.
They already often have so many strikes against them – no medical
home, underemployment, no children receiving Medicaid or SCHIP benefits, and stigmatization
by policymakers who equate illness with entitlement.
They don’t need insurance with all of its profit motives, administrative
costs, and bureaucratic tangles. Their
providers just need someone to help pay the bills.
And states need the $20
to $40 billion Medicaid expansion would add to their revenues over the next
five years if people with behavioral illnesses were added to the regular
Medicaid program.
Premium support is
better than nothing.
It may ultimately win the blessing of HHS, and in some
states premium support may be the only path to expansion.
But premium support is only a partial expansion of the
Medicaid program – a concept rejected by HHS just months ago.
And this partial expansion will leave some of those most in
need sitting on the sidelines again.
To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com. Twitter: @pgionfriddo. Facebook: www.facebook.com/paul.gionfriddo. LinkedIn: www.linkedin.com/in/paulgionfriddo/
I'll certainly be back.
ReplyDeleteEssential Amino Acids
It’s troubling when you think about how Medicaid seems to be an unsustainable way of caring for our people, especially the elderly and low-income earners. I’m a single woman, childless, and living alone, so I decided to deal with my healthcare anxieties while I still can. I looked into drafting a living will to express my care preferences and also checked long term care insurance - www.novalet.com/jordanhill/post/why-compare-long-term-care-insurance-quotes because I don’t want to rely on Medicaid in the future.
ReplyDelete