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How Would Medicare Part C – Medicare Advantage Program

Trump Ball Naples

Pouring money into ACA or a Graham-Cassidy block grant version of the reform, is like beating a dead horse. It is just another way for Congress to waste money. Reducing Medicaid has its own set of problems. AHCA is better than nothing but we can do better. Here is how Medicare Part C plans would work for the American people:

A) Medicare Part C

Medicare Advantage program (MA) health plans for uninsured under age 65, would function like they do for over age 65 retirees. The focus would be on contracting with health insurance carriers and HMO’s to deliver Medicare Part C plans using per capita financing. Medicare Part C programs would be required to offer coverage that meets certain standards but would be flexible enough to allow broad differences in benefit levels to accomplish certain goals for affordability. For continuity coverage, we will continue to allocate the Plans to the three valuation titles of Bronze, Silver and Gold (and add a Copper choice if necessary). CMS will determine basic but flexible parameters that will insure a consistent level of benefit uniformity throughout the states, not quantitatively as high Medicare Plans A, B and the Medicare Part C - Advantage Plans for Over Age 65, but certainly a highly consistent level non-the-less. Health insurance carriers will not be required to provide the Ten (10) Essential ACA Benefits. A sub-set of those benefits would be negotiated between CMS and the health insurance carriers such that Core benefits will include those necessary for the treatment of illness or injury. Lifetime and other benefit limits will be allowed. Additional benefit riders can be added to plans. These riders will be permitted to cover Mental & Nervous, Maternity, Alcohol and Drug Addiction, Dental Care, Prescription Drugs, Rehabilitation and Therapies. Basic benefit plans will be designed to have the lowest possible rates. The CMS rules will permit health insurance carriers to go back to the comprehensive major medical contracts they had been selling prior to ACA.

However, a new addition to the Core benefit package will be specifically designed for the promotion of improved health and well-being. This Health and Wellness package of benefits will include at a minimum, Health Club and other active Sport and Exercise Club Dues and Gym memberships, personal trainers, dietitians, weight loss and smoking cessation programs and other professional and practical coverages that have the proven potential for improving the insured’s health and lowering their utilization of health services, excluding exercise equipment. The future of reducing the national cost of health care is improving the health of our citizens to lower their need for health care services. This will become a national priority and be promoted by CMS and the carriers in a big way.

Copayments and deductibles will be encouraged and all insured members will be required to pay them, regardless of their income. Benefit designs will be cost effective, with limited Emergency Room accessibility, Emergency Ambulance transportation and no unnecessary health procedures. Primary care visits and a limited amount of first dollar coverage for annual physicals and related lab work and examinations will be encouraged.

Medical necessity will be required, however a special new classification of benefit for Experimental Procedures will be required as part of the Core benefit. This coverage will be under CMS management practices. Approval by CMS would be required for any changes to Core Benefits. The review will work the way the FDA handles new pharmaceutical products. All experimental procedures, like ground breaking cancer treatments such as Ablation-Radio Frequency, Cryo-Ablation, Microwave-Ablation and other treatments that have shown promise in curing illness, especially those that are less costly than the more common medical and surgical practices. HMO and carriers may offer programs that provide full coverage for all services, however deductibles and coinsurance will be recognized as tools to influence the behavior of people seeking health care. If everything is paid for, no one will ever think twice about where they go for treatment or how much it costs. Special reimbursement for health insurance carrier cost sharing should end for everyone immediately.

The best and most expensive plans will include many of these options. There would be many choices. Health Insurance carriers would be precluded from making changes to any benefit programs without prior CMS authorization and required notifications to the insured. Programs will be specifically design to reduce medical risks, promote healthy behaviors and physical exercise and reduce the waist lines of all Americans. We need to make our people want to be the healthiest people on the planet Earth, rather than the most rotund and well fed. We need to encourage our elderly to walk. If you have been to an amusement park lately, you can’t help but see the number of obese people getting around with scooters that are paid for by Medicare. Ninety (90%) percent of those adults would be walking if Medicare refused to buy their scooters. I was catching a flight out of Florida and a dozen or more passengers showed up at the gate in wheel chairs. The stewardess very smartly suggested that the departure would be significantly delayed if everyone in a wheel chair required special boarding and invited anyone that could do so, to walk onto the plane themselves. After a few minutes, there was a sea of empty wheel chairs at the gate and the plane departed on time.         

B) Capitated Premium Required

Capitation rates are a method of cost containment developed by insurance companies and CMS as an alternative to fee-for-service payments. The idea is simple. The carrier pays a medical provider (like primary care physician - PCP) a set dollar amount each month. The provider agrees to provide a subscriber medical services in return for the capitation payment. The theory is that only a few of the subscribers will need to see the PCP, and the fees for everyone will more than cover the cost of those few patients that avail themselves of the PCP’s service. The Chinese apparently only pay their doctor when they are well. A PCP makes more money taking good care of their patients without requiring any unnecessary service. In addition, there is a built-in incentive for the PCP to keep everyone healthy. Usually an annual physical is part of the package. Eventually this practice was used between payers of health insurance, like CMS and their health insurance carriers and HMO’s. This method of reimbursement has many utilities, the most obvious of which is its predictability of future costs.

Under the expansion of Medicare Part C, under age 65 members will typically pay a monthly premium for the cost of their Plan, plus any additional benefit riders like maternity and mental and nervous benefits. Whoever and whatever Congress doesn’t choose to pay for, will be charged as premiums to the members. CMS will do the same thing for under age 65 participants’ in the Medicare Part C expansion that they currently do for the Over ager 65 retirees. They will calculate a reimbursement level that is equivalent to what Congress is willing to spend and whatever balance that may be necessary to cover the full cost of benefit plan will be paid by the subscriber.

This is exactly the way Obamacare works. The members are responsible for paying the premiums for their ACA health plan. In the case that their annual income qualifies them for a government subsidy, the premiums that they would otherwise be required to pay are reduced by the subsidy, which together pays the full cost of the plan to the health insurance carrier. This same level of funding can conceivably be achieved using tax credits, which may also be permitted for higher income earners. Whatever tax credits we estimate the members will qualify for at the end of the year, is the level of additional funding Congress can make available to the program, along with the application of other dedicated revenues from taxation.

Most of the ACA participants are receiving a premium subsidy now. That may be the principal reason they remain on the plans. In 2016, CBO estimates the ACA premium subsidies will cost the federal government 27 billion dollars with an additional 7 billion dollars in cost sharing for a total of 34 billion dollars. This is expected to rise to 67 billion dollars by 2020. I think the CBO has purposely underestimated these costs and the Senate has proposed keeping a good deal of that funding intact. (26.)

C) New Business – The Uninsured 

Several of the Medicare Advantage programs would be specifically designed to attract a majority of the uninsured. No one will be required to sign up for the program, but there needs to be a mandate even though the most recent studies indicate that the mandate is of limited value to the low-income consumer and is not sufficient to prevent adverse selection. The goal is to get everybody to have health insurance. To get as close as we can to this goal, we must create an incentive to buy it. Unfortunately, the effect a mandate has on the willingness of a low-income adult to pay for health insurance is difficult to measure. Mitigating factors include, waivers, as we have seen with ACA. Moreover, individuals may discount the mandate penalty because it is difficult to determine and normally incurred when they pay their following year’s taxes, if they are aware of it at all. The goal is best achieved by having a vague but conceptually very real consequence to not buying the insurance, like the One (1%) percent mandate used for Medicare Part D plans. 

If an otherwise eligible uninsured person DOES NOT SELECT the MA program when it is first offered to them, they will begin to accrue a deleterious sounding surcharge that will be applied to future premiums on any MA program they subsequently buy in the future, in the same way that Medicare Part D handles those citizens that do not enroll in a Part D Prescription Drug Plan.

If we want people to buy car insurance when they drive a car, we require it by law. We don’t say, “If you don’t want to, you can drive a car without paying for it.” We know that when an uninsured driver has an accident, which is more likely when they cannot arrange for insurance in the first place, the driver may injure someone else and no one has the right to do that. If the people that don’t buy health insurance have an accident, and require health care that ends up being partially paid, or not paid at all, there is supposedly upward pressure on everyone’s cost of health care. No one should have the right to do that either. 

Even with subsidies, only half of low-income eligible will buy health insurance, so we have to get creative. We will establish the requirement for people to have health insurance. We don’t let anyone anywhere drive a car without car insurance. That is because they can injure themselves or others with their car and society needs to require them to have a way to pay for it. Accidents will happen. People will get sick and require health care. Health care, in a healthy free market economy, costs money. Society requires them to pay for it. If they don’t have car insurance, they must go to court and they may have to go to jail.  If they don’t have health insurance, they will suffer all the credit and debtor problems we have in the system today, in addition to a higher cost of health insurance in the future.  If we are successful in getting most of the uninsured covered, the uncompensated care problem will be minimized. 

D) Pre-Existing Conditions 

Any uninsured applicant with a pre-existing condition, which they have not been able to insure for more than 60 days in the past, will qualify for a special State Fund for High-Risks under Medicaid. Coverage will be available anytime under this Special Risk Pool (SRP). The federal and state governments will share the cost of SRP under the Medicaid program.  

Everyone, who has been diagnosed with a pre-existing condition, that has been able to qualify for health insurance, or because they were insured when the condition developed, will be able to walk up to any Medicare Part C carrier and get full benefits for that condition under any Medicare Advantage program, provided the coverage has been active no less than 60 days from the effective date of the new MA plan.  

Most people think that a pre-existing condition is something someone was born with or contracted by accident. Pre-existing refers to the onset of an illness “before” a person had health insurance. To have a preexisting condition, a person has to have been diagnosed with illness, like lung cancer or a tumor that developed before they were covered for it by a health insurance plan. Accepting them into a health insurance plan is like allowing them to burn their house down and then go to a property-casualty insurer expect them to pay for it. These conditions are not anybody’s fault. They happen and people sometimes go long periods of time without health insurance. There is generally little that a person could have done to avoid the illness. But if they did not have health insurance at the time the condition was diagnosed, it is their fault that they did not have health insurance.  

We must come from the premise that all citizens of the United States should have health insurance. If they can’t afford it on their own, they should get it from the government, just as they would if they were insuring their house or their car. And, how much more important should it be for them to cover their bodies? There are too many people who have gotten too used to being without health insurance. If we allowed everyone to avoid health insurance until they get a serious illness, no one would ever get insurance until they seriously needed medical treatment.

The problems with that include:  

·         They haven’t paid anything into the Plan to help defray the cost of their treatments.
·         The cost of their treatments to get the condition cured or arrested are usually very expensive.
·         The Risk Pool is tainted by a predominance of people, who only require the payment of benefits, commonly referred to as “adverse selection”.

Letting these people join a health insurance plan abrogates the principles of a sound actuarially underwritten health insurance contract. The healthy people join a plan to be protected from unexpected medical expenses from a future illness. But, they hope they will never have to use the plan and their premiums pay for people that do. If too many people sign up for coverage because of an illness, the premiums for the plan will eventually have to increase to cover the cost. The plan is then required to pay out more than it takes in. This naturally migrates into the so called “death spiral” of a non-group risk pool, which eventually causes the plan to collapse. The healthy people find better deals with a new company. They drop out of the plan, leaving the sick people, who can’t afford to leave the plan or find alternative coverage.

Something like this is happening to Obamacare. The collapse of the plan leaves everyone uninsured and having to start over. The difficulty for many of the people starting over, is qualifying for coverage now that they have a pre-existing condition. Hence the urgency of finding an alternative plan that will accept them within 60 days. What many people tend to forget is that this is the way health insurance worked in the U.S. since the turn of the century. The exception is with employer group insurance. After an employee qualifies for group insurance, they are accepted for all medical conditions, no questions asked. An obvious problem exists with people, who can’t find a job that offers health insurance or cannot work due to their illness. Further, there are many more people stuck in dead end jobs that they hate because they have a medical condition that requires health insurance and they fear if they move on to a better job, they may loose their health insurance.

BCS believes that Medicare Part C plans should not be required to take anyone with a serious and costly pre-existing condition that has not had coverage for that condition for more than 60 days. This at least helps the MA plan by maximizing the possibility that the new enrollee has their Pre-existing condition under control, i.e. has had a successful surgery, arrested cancer with chemotherapy, or stabalize their condition on maintenance drugs etc. These treatments and drugs will be covered, not denied as related to a pre-existing condition, even though they allowed the applicants condition to remain under control and in remission. This is the kind of fuzzy headed decision making on the part of health insurance carriers, that got us in to this whole mess in the first place. A lot of people have pre-existing conditions that don’t cost any money because there is no treatment for them. 

CMS and the states will agree to accept and pay for all pre-existing conditions under a “pay as you go” Medicaid plan. And, insurance carriers will be encouraged to use all reasonable underwriting practices that protect their risk pools and do not result in the denial of coverage for anyone that wants to sign up. No one with a pre-existing condition will be turned away. However, they will only and immediately be eligible for Medicaid, regardless of their income level, if they have a break in coverage over the 60 days. A period after which they may have the condition under control, they will also be included in periodic Open Enrollments in the MA Plans, in the same fashion as Original Medicare.  

Carriers will conduct periodic Open Enrollments and allow all citizens to join a plan of their choice without any medical qualifications. And, the insurance carriers will not be prevented from reasonable underwriting that protects their risk pools and does not result in the denial of coverage for anyone that wants to sign up. The insurance carriers would be required to work with the capitation rates developed by CMS and to determine the risk of their benefit plans, underwrite them and live with the results. This should eliminate the need for federally subsidized rate and market stabilization and large loss recovery funds that are currently crippling the cost of Obamacare. 

A major problem with Obamacare is that the people with pre-existing conditions can join the insurance pool. They generally have not maintained health insurance or they have been dropped (which should be illegal) and their condition in some cases has gone untreated and is not under control. Medicare Part C Plans should accept anyone with a pre-existing condition that has maintained insurance coverage for that condition. The “Pre” in pre-existing is “before any health insurance”, not just Obamacare. The Senate repeal and replace bill and the AHCA proposes to sur-charge an extra arbitrary 30% in premium and also for Congress to pay more money to compensate health insurance carriers for accepting these risks. 

To avoid these charges, we must keep these risks out of the insurance pool, as has historically been the case. What we can do instead, is give them coverage under a “pay-as-you-go” Medicaid plan. The coverage will be limited and they will have to pay some premiums just like everybody else. But they will NOT be turned away. Rather than penalizing them, this will create an incentive for them to get and keep health insurance coverage and get the condition under control so that they may qualify for one of the Medicare C plans in the future. 

E) CMS And Not The States 

This is the most important reason you should vote to scrap Obamacare and shun Block Grant type programs. Medicare is a national program. Obamacare was trying to be a national program, but relies upon the states for exchanges and other services. If we replace ACA with a program that gives the states options to change the nature of the plan in their state, we will have a plan for each of the fifty states. But, we will NOT have a national plan. If we do eventually have State plans, the federal government will eventually require the States to pay for their plans.

I don’t think an insurance plan of this importance should vary by state. A plan on this scale would not be more successful being organized under the state governments.

Obamacare and the Medicaid programs are good examples of that truth. Congressional Reform Proposals have already shifted some of the ACA responsibilities for this national health insurance program to the states, like the Marketplace Exchanges.  Whenever, the federal government runs into financial challenges, Congress tends to propose block grant financing and other similar enticements to shift federal responsibilities onto the state governments.  In 2016 total Medicaid spending equaled 550.9 Billion Dollars. Historically, the federal share has averaged about 57%; however, under the ACA, the matching rate is higher at 100% for newly eligible participants. Starting in 2017, the matching rate is supposed to decline slightly until it reaches 90% in 2020.

This is what the states seem to want for Medicaid. The Graham-Cassidy Bill promoted a plan to whole sale block grant the entire health care program to the states. In the healthcare arena, states have been challenged enough to provide adequate funding for their Medicaid programs, even with an unlimited 50% match funding from the federal government. Medicaid plan eligibility, administration and benefits vary widely among the states. Gaps in the programs require local resources to fill and increase the level of uncompensated care for our major institutional providers in many areas. Although this may be appropriate due to the uniqueness of each state environment, states should be alarmed when the federal government is proposing cuts to the Medicaid program funding and relinquishing decision making and granting waiver authority for the market-based insurance programs. The natural progression of this activity will be the increasing demand for state financing associated with public-private market programs and greater reliance on the state property tax base of which very few are in favor.    

In this Medicare Part C – Medicare Advantage plan, health insurance carriers will be primarily responsible to CMS for the Medicare Part C Plans. The carriers will be given broad authority to develop cost effective plans and manage program benefits and the treatment of health conditions. Serious attention will be devoted to promoting the health and well-being of the insured, using specific benefits designed for that purpose. Carriers will have incentives and funding to develop innovative cost containment programs and rewarded for programs that can be shown to reduce the cost of health care for their members.   

State authority will be limited to the normal regulatory functions associated with their health insurance companies and the running their Medicaid programs. There should be coordination between the states’ Medicaid programs and CMS Medicare Part C Plans, such that eligibility and movement between programs is seamless, as HHS has suggested it should be. 

F)  The Primary Responsibility For Marketing

Health insurance carriers and states will NOT be required to financially support the Marketplace Exchanges. They were supposed to be self-supporting by this time anyway.

The health insurance carriers and HMO’s will be required to handle enrollment and billing as well as the marketing and full customer service for all plans. They will be required to provide all the information and product support, answer all questions and solve any and all problems. Health insurance carriers routinely handle these functions for Medicare Part C – Medicare Advantage for over age 65 retirees and their own private market products and they are the best source of the necessary information and administration to handle these issues. The marketplace exchanges are redundant and the cost of running them should NOT be financed by the health insurance carrier, the states, or the federal government.

Who do Obamacare enrollees call when they have a problem? Do you call your federal or state Congressional Representative or administrators? Obamacare has practically no accountability built into its structure. If there is a successful Marketplace Exchange, it is in CA. California has merged their state-wide health insurance program with ACA. Private insurance agents are activity involved in enrolling new members and some very positive things have been written about the system. But, there are still big problems and they seem to revolve around the issue of accountability. Who’s in charge? If you want more information on this, please visit my friend Kevin Knauf’s blog. Kevin is an extremely knowledgeable agent for both Covered California (ACA) and Medicare Advantage Plans. His perspective on Medicare Part C – Medicare Advantage and the efficacy of expanding the program to include the under age 65 population is in parallel to BCS and yet we are on opposite coasts in very different insurance markets. Reading his blog is both edifying and illuminating. You can find Kevin’s Blog at: https://insuremekevin.com/medicare-advantage-health-plans-as-blueprint-for-replacing-affordable-care-act/#disgus_thread/  If you are wondering how CA is doing, check it out.

As a Florida resident, I personally enrolled in ACA through the federal Marketplace Exchange, because Florida declined the Medicaid Expansion program and rejected the creation of an Exchange. I first established an on-line account and then forgot my User name. There was No mechanism to find out what my user name was, to change it or to set up a new account. Although my enrollment was easy, in some states almost 20% of the enrollments in the program have problems. ACA does the reverse of what most health insurance carriers do. Everything starts with the Marketplace Exchange and then flows to the carrier. Whereas with Medicare Part C – Medicare Advantage an applicant first contacts the insurance carrier and they get their enrollment records directly from the applicant. This makes for a smoother and more accountable enrollment. An applicant usually has a point of contact (a person or company name) and issues can be more easily be resolved. More importantly, CMS is so protective of their retirees that MA carriers literally shudder to think that a complaint may be logged against them for any reason. They train their agents exhaustively on all aspects of the program and they do an excellent job of enrolling new members and adhering to CMS guidelines. And, the carrier’s telephone Representatives are licensed insurance agents in the states in which they enroll. They are also compensated based on their enrollment and they are crack agents at their jobs. Federal marketplace agents are not licensed, and the do a very good job, but they are not qualified to enroll anybody in anything other than ACA and that is a draw back. Under Obamacare, you just don’t know who to call. Can you call your Congressional Representative for many things, like provider non-compliance, incorrect tax forms, claims and billing problems, etc? Otherwise – who you gonna call (Ghost Busters)?

G) Medicare Part C Funding (Under Age 65) -

Medicare Part C (for under age 65) will be funded separately from the Medicare Advantage Plans for over age 65 and the disabled. There will be no overlap, mixing of risk pools or dual eligibility. In the event of dual eligibility with Medicaid, etc., the enrollee will be required to select which program they want to use. Over age 65 programs and procedures would remain the same. Like the over age 65, all private market participants will be required to pay premiums for the programs. These premiums will be self-supporting, provided the program is successful in attracting most of those lacking health coverages. 

The primary purpose of the Medicare Part C plans for Under age 65 is to increase the number of people covered by health insurance, enabling them to have easier access to health care services and to lead more productive and healthier lives. The result of establishing this program will be a much lower incidence of uncompensated care, especially for our hospitals. This program will increase the overall demand for health care and related services, improving the earnings for providers. Health insurance company’s and HMO’s will benefit from increased enrollments and all businesses, including those not providing health insurance, will tangentially benefit from a higher worker productivity. 

Eventually, every institution, organization and individual in the health care business that will benefit from the success of this program should contribute financially to its success. Taxes should continue to be levied on hospitals, doctors, insurance companies, HMOs and all the other health care related institutions that benefit from this health insurance program. In addition, all employers with more than 20 employees, that do not have a health insurance program for their employees should be required to contribute something and offer automatic payroll deduction services for anyone enrolling in Medicare Part C. We need to do more than just levy a temporary investment earnings tax on the rich. However, the  ACA taxes that have been in moratorium should be abolished until such time as a new successful health insurance program is agreed upon. Why should insurance companies be taxed to support a failing program that has cost them money in losses and implementation experiences, when most carriers do not administer or gain any benefit from ACA enrollment? Once a successful program, with insurance company support and assistance,  healthcare related tax base from combined sources will be able to stabilize funding for the program. It will create a revenue stream, like payroll taxes that support Original Medicare and eventually become part of the fabric of our everyday lives, like Medicare A and B. 

H.) Medicare Part C - Program Creativity And Flexibility

If we don’t have creativity and flexibility in this program, we will have socialized medicine by mid-century. The only thing that is going to lower the cost of health care in the United States is creative benefit administration, cost containment, health promotion and well-being behaviors. We need to have a health plan that we can adjust to accomplish our changing needs, like covering more of the remaining uninsured population. The Medicare Modernization Act of 2003 payment formulas for Part C plans were increased by 12 percent or more on average, to increase the availability of Part C plans in rural areas and inner-city neighborhoods to increase the percentage of rural and inner-city poor retirees that could take advantage of the program. Although questionable Congressional wisdom, has cut this program, (in part to provide more money to fund Obamacare) the program was a success. Competition between insurance carriers is what we DO NOT HAVE in the Affordable Care Act (ACA) marketplace today. However, in 2018 the average Medicare Advantage (MA) plan participant has access to TWENTY-ONE (21) different plans. Historically, 99% of all Medicare Beneficiaries have access to either a MA HMO, PPO, PFFS or a Regional PPO. This is NOT your father's Medicare! This is the answer to how we get to a reasonably priced health insurance plan for everybody. MA is not available everywhere yet. In it's present form it is NOT exactly ready for everybody, but as a nation, this is OUR answer. Medicare Advantage is a program upon which we can build a National Health Insurance Program that WORKS! ACA Plans will never be able to compete! Go to www.bcsconsultants.net and learn what you can do to make this happen!  Medicare Part C programs have historically cost the government the same as, or upwards of 5% less on average, than it cost to cover the medical needs of comparable beneficiaries on Original fee-for-service Medicare. This is an example of what a rational national policy can do to deliver a successful health care program for the American people. It is hard to see how this could have been accomplished in each of the 50 states.

The health insurance carriers for the Medicare Part C programs generally develop favorable contracts with health care providers that may save them more money than it costs them to administer their benefit programs. A PBS Documentary on Medicare Part C Plans uncovered the fact that some Part C carriers could almost save more money through provider contracts than they had to charge for their administration. This is one of the ways health insurance carriers make money. The challenges for the government include making sure the insurance companies are paid enough money to have profits and to motivate the carriers to factor the profit back into their cost of administration.

Astute publicly oriented health insurance carriers would generally not expect to earn much more than their reasonable cost of administration from a government funded entitlement program. They would naturally pass on most of their profits to the government to keep the business. This is how the non-profit BlueCross BlueShield Plan System worked before Congress made the questionable decision to tax the non-profit BCBS Plans like commercial health insurance carriers. Most of the Plans lost money annually by passing back more of their income to their customers than they earned. The short sighted politically motivated change in taxation removed the impetus for the BCBS plans to remain non-profit. This resulted in consolidation and privatization of the BCBS businesses and the loss of their non-profit health insurance orientation.

We need this non-profit altruistic flexibility when it comes to dealing with the uninsured population. The idea that insurance carriers should be allowed to apply to the states for waivers in a national program that could potentially cover over 40 Million citizens is ludicrous. This idea will make it very difficult, if not impossible, to change the program to respond to changing conditions nationally. More importantly, to bring the cost of health care under greater control, the U.S. will be required to change consumer behavior. A national plan will give CMS and HHS the flexibility needed to accomplish this goal. This effort, albeit not undertaken as yet, is critical to our future viability as a nation. There is no compelling reason for us to make it more difficult to accomplish.

The Republicans are planning to promote a 50- state program monster. When the Senate came out with the Graham-Cassidy bill, I called it Obamacare Dark. For the moment, this option appears to be dead. However, if it rises like a phoenix, the federal government will eventually seek to dump the substantial cost of these programs onto the states, in the same way as with Medicaid. Nineteen (19) states did not believe the federal government would continue to fund the Medicaid expansion created by ACA. In this climate, who would believe that the federal government will continue to fund any state run obligations for an extended period?

One of the beautiful things about “ALL” the Medicare Part C programs for Over age 65 is that they are designed to be equivalent to the Original Medicare program. Retirees moving from one state to another don’t have to worry about being able to obtain a certain level of Medicare Part C – Medicare Advantage health insurance coverage in their new home. 

That is the security they paid for with their payroll taxes and that is what CMS delivers for those over age 65. And, CMS will be able to do it for a Medicare Part C expansion. But they will not be able to do it if Congress is successful in giving every state the right to create their own “national” health care insurance plan, one state program without necessarily a consistent level of coverage with the next state. The number of uninsured is a national problem and it requires a national solution. State tax payers have enough challenge paying for and improving their Medicaid programs for the most needy of their residents. Making Medicaid programs consistent from one state to another is also a worthy goal. How else are we to know where one program is supposed to end and the next one to begin? 

In some states, health care for the poor just doesn’t rise to a high enough priority level to warrant any special attention and resources. However, Politico recently reported that some of the push back against the ACA reform bill in the Senate is coming from unexpected political support for Medicaid. According to Diane Rowland of the Kaiser Family Foundation, “We are finding that Medicaid has a constituency that may have been underestimated.” On the other hand, there are states that devote an overwhelming amount of attention to their Medicaid programs.

Florida Governor Rick Scott is a proponent of CMS helping the states innovate and improve their Medicaid programs with what he refers to as a 50 state incubator experiment for Medicaid program development. Even though CMS professes flexibility, some states have been frustrated by the required federal approvals to change their Medicaid programs and the rigorous process for waivers and permits that delayed and prevented some states from making improvements in their programs. My guess is that one of the goals of this approval process was to use the federal purse strings to force the states to deliver a certain level of benefit and eligibility uniformity in the state Medicaid programs. While I am a proponent of the idea of uniformity, whether this is a necessary or a worthy goal with State run programs is debatable. I believe Governor Scott has successfully lobbied for Congressional approval of state Block Grant funding, to give states the financial flexibility they may need to improve their Medicaid programs. The survival of this idea in any subsequent legislation remains to be seen.

State budgetary challenges are a huge issue. In 2017 the ink wasn’t even dry on the proposed ACA repeal efforts that will cap the federal spending on the Medicaid program and the State Legislators in Florida felt it necessary to approve a reduction in the Medicaid payments to hospitals by 521 million dollars in 2018. This is half of the One (1) billion-dollar reduction in the Medicaid budget that Governor Rick Scott requested, due presumably in part to punitive federal cuts in the Florida Low Income pool funding, in retaliation for not accepting the Medicaid Expansion Program.

Medicaid programs are not uniform, or reliable state to state, year to year. Many experts believe the states are financially incapable of handling the “Marketplace” ACA reforms, on top of the state Medicaid budgets caps. If YOU don’t want your state to end up footing the bill for the “Obamacare Dark” block grant approach to national health insurance, you had better get the Republicans to change the state sponsored aspects of the proposed Republican health reform bills, before it is too late!