Oops, I missed some days….

I’m very sorry I was a bit delayed on some days. Michael Anne, my co-blogger has been very diligent to be posting away while I have delayed. I blame the fact that I’ve been ill, but I’m none the less sorry to all the loyal readers (hi dad!).  But here are the posts that I didn’t put up in time!

Day 35: Medicaid at 50– State Highlight: Rhode Island

Rhode Island covers 272,362 people through it’s Medicaid program.

What is better than connecting Medicaid with your first name? Connecting Medicaid, your first name and the great state of Rhode Island. TheEmma Pendleton Bradley Hospital is the oldest pediatric psychiatric hospital in the country. It serves children and adolescents across the state with mental health care.

Medicaid doesn’t pay for inpatient facilities for mental illness with more than 16 beds. This is known as the IMD exclusion. When Medicaid was first enacted (almost 50 years ago, duh), Congress didn’t want the program to replace existing state funded programs that payed for institutions of mental health. However, since the 1960s, states have been deinstitutionalizing their mental health programs, leaving a gap in coverage for many people. In 1972 Congress changed that exemption of inpatient services for children up to 21 years old. This means that children seeing services at the Emma Pendleton Bradley Hospital can have their services paid for by Medicaid. The hospital currently takes Rhode Island’s Medicaid reimbursement. This is great for the children of Rhode Island, but unfortunately, adults are not afforded the same benefit.

Day 34: Medicaid at 50– State Highlight: Utah

Utah covers 303,963 people in it’s Medicaid and CHIP programs.

You might be watching these state Medicaid 1115 waiver demonstrations and be thinking, “Wow! These policies are sooo new. I can’t believe that no one thought of it before!” Well, here is Utah to burst your bubble.

In the early 2000’s Utah’s Republican governor Mike Leavitt initiated and negotiated a waiver demonstration (before Mitt Romney even tried in Massachusetts). This demonstration extended coverage to uninsured parents and other adults up to 150 percent of the poverty line. The demonstration included cost-sharing for these low-income individuals and primary care services. It was not anything close to Medicaid expansion however (or what Massachusetts would later implement). There was a very limited hospital benefit, basically only covering emergency room services. If a person needed surgery or other hospital services, the state would work with hospitals or doctors to provide the individual with charity care.

Utah is currently debating their Medicaid expansion plan. This primary care demonstration is a foundation for building the expanded coverage to low-income adults in Utah. Again, the program is not expansion — the benefits are so limited that it essentially just pays for primary care and ER services. However, the state must remember, before Obamacare, the state was leading the way with extending Medicaid coverage to adults.

(By the way, this information was mainly from the book Medicaid Politics by Frank Thompson. You should buy it!)

Day 43: Medicaid at 50: Safety Net Hospitals

Safety net hospitals serve a large portion of the uninsured and low-income people that would likely be eligible for Medicaid (at least expansion). Either due to state mandates or a mission of providing care to all people, regardless of ability to pay, safety net hospitals disproportionately provide care to people that is often not compensated. In 1981 Congress established the disproportionate share hospital (DSH) payment adjustment in the Omnibus Budget Reconciliation Act of 1981. This law provides additional federal funding to states to disburse to safety net hospitals. While these payments are important to the hospitals, the payments dwarf the cost of treating the uninsured, even with Medicaid’s low reimbursement rates. The DSH allotments to states are set to decrease…eventually.

These DSH allotment decreases and the decrease in uncompensated care in Medicaid expansion are some of the key factors that influence credit rating agencies like Moody’s. Creditors are looking closely at state expansion decisions and congressional decisions on DSH. A better credit rating because of being located in an expansion state could lead to a hospital’s ability to borrow at a lower rate and improve their facilities, that could lead to better care for Medicaid beneficiaries.

Day 42: Medicaid at 50– Medicaid helps state credit ratings

Earlier, I mentioned that Medicaid helps improve a hospital’s credit rating (see above). But Moody’s has also indicated that Medicaid expansion will play a role in their determinations about the overall state’s credit rating. States use these credit ratings to improve their interest rates and borrowing power for infrastructure and other investments. The Medicaid expansion boosts economic stability and keeps people out of poverty. This is good for the state because that can turn into greater revenue and a more productive labor force. The expansion also fills gaps that some states fund for uncompensated care and other services, bringing in additional funds to the state and reducing costs in other programs. This improves the overall budget stability for the state.

Day 41: Medicaid at 50– Many Medicaid beneficiaries are working

One myths of the Medicaid program is that all the people that receive Medicaid aren’t working. This isn’t true! Many people on Medicaid are working, but just not making enough to get subsidies on the Marketplace or not employed by companies that offer health insurance. Additionally, many Medicaid beneficiaries are disabled, elderly, and children– populations that have low employment rates for fairly straightforward reasons.

I can’t really talk about this point better than Drew Altman– and frankly very few people can. So you should just reread his Wall Street Journal explanation and pretend like I was saying it (for my self esteem).


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