ACHAWUUUUUT: Block Granting Medicaid

Yes, the list of preconditions that states may adopt to limit health care coverage astonish in their cruelty. That’s covered (and fact checked), as is the reverse Robin Hood jujitsu that should not surprise us from an Administration whose only principle is endless expansion of profit. Covered less is the AHCA’s devastating impact on the Medicaid system. So here are a few pretty good analyses of how block-granting Medicaid might work. Research!
Indeed, AHCA curbs spending, which sounds great to small government folks. But it does so by simply not paying for health care for people who need it most–low income people with disabilities and chronic conditions. People with health problems and an inability to pay for care on their own. Gutting Medicaid will blow up emergency room costs as well as indirect costs in the criminal justice system, special education, welfare, and other places that people with no health care end up.
AHCA’s Medicaid provisions will set up a tiered society in which health care is a privilege reserved for those who can pay for it. Health care austerity will cost our society in ways comparable to climate change: pervasive, universal, tune-outable for the less vulnerable and willfully ignorant, and devastating for the rest of us.

The ACA (long live Obamacare!) curbs spending in multiple ways: investing in health IT improvements, focusing more intensively on fraud, and setting up pilot programs in payment reform. Colorado uses these supports to move towards paying for value rather than volume, and to build up better systems for preventive care (including mental health and substance abuse care). Lots of states are doing this. That’s the “innovation” stuff that gets perverted into “creative destruction” by our technocractic Steve Jobs culture but that is necessary to shift payment and cultural infrastructures to help medical professionals do what actually works (whole person care) for less money (risk-sharing, incentive payments, lots of other jargony-sounding set-ups). I’m particularly excited about the federal grant to integrate mental health and physical health care across the system here–not just in Medicaid, but in all payers.

Instead of Paul Ryan’s sadistic dream of just not paying for care, the ACA pays for care and also invests in changing our system to provide better care at a lower cost. Repealing these programs would set the whole health care system back several decades, when we believed that “health care” meant curing disease rather than promoting integrated, multi-dimension, whole-person wellness.

Regular TfH readers are unsurprised to know that I believe that the flaws of the ACA lay in its dependence on private market-based players. (I’m talking primarily about the increased premiums and the exchanges that were shut down when promised federal money was withdrawn.)  Repealing individual insurance mandates and cutting exchanges would cripple the system by sucking out the funding, so then people who think they hate “Obamacare” can prove to themselves it was a bad idea. (Mirroring most small-government strategies of gutting government to convince voters that government is the problem rather than the solution.)

Per capita caps on Medicaid spending will ripple out to a loss of health care for millions of currently covered people for reasons outlined in links above: People will max out their cap really fast, doctors will drop out of the program and skimp on needed tools, and innovations in care and quality will be barred from the populations that most need them.

A “better way” to curb health care costs would be either to continue with the ACA but add a public option to keep private insurers competitive (and invest in payment reform and trauma-informed, integrated mental/physical health care for better health outcomes. Plus government regulation to keep the private insurers from screwing over their clients) (this is prob what HRC was going to do); or just go full single payer and eliminate private corporation overhead and malfeasance.

The ACA is great and would be better if it could be fully lefty nutjob commie, but I’ll take what I can get. I will join every major professional medical, mental health, and human services org in mourning the coming hacks to it and their impact on millions of the most vulnerable people and on the systems built to serve them.

Underlying my AHCA-nxiety is my believe that equitable health care (including strong mental health care) can be the kind of tool for ending, or at least mitigating, poverty, that we all seem to want education to be. And, of course, the reverse would be better. The real way to cut federal and state health care costs would be to end poverty.


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