How the HIV outbreak in Indiana under Mike Pence would have impacted Indiana under Per-Capita Caps

penceIn 2014 and 2015 Indiana suffered a preventable outbreak of HIV as a result of the opioid epidemic in the state. During a one year period 181 people were diagnosed with HIV in Scott County, Indiana alone and nearly 90 percent were the result of intravenous drug usage. A defining moment in Vice President’s Gubernatorial career, Pence is most known for implementing a needle exchange program despite his opposition to such policy. Yet, less well known is the role that Medicaid played and continues to play in the HIV outbreak and how the current per-capita cap and block grant proposals would have impacted Indiana if they had been in place at that time.

Medicaid plays a vital role in the treatment and testing of HIV patients, throughout the history of the program. An estimated 40 percent of HIV patients are covered by Medicaid, making it the largest insurer for HIV patients. Medicaid costs are increasing as patients are able to live longer and the cost of drugs and other care continues to increase. Overall, Medicaid is the second largest federal funder of HIV care and HIV patients account for 1 percent of those enrolled in Medicaid and account for approximately $9.4 billion of state and federal costs or a little less than 2% of total Medicaid costs.

The average HIV patient costs Medicaid about five times those of Medicaid beneficiaries overall averaging over $26,000 a year in 2011 for an HIV patient compared to approximately $6,000 a year in 2011 for other Medicaid beneficiaries. Part of this is because many of those enrolled in Medicaid are children who are relatively inexpensive to treat. As mentioned previously, the cost of drugs for HIV patients continues to increase, as was notable with the 5,000 percent (then lowered to a 2,500 percent and a mere 874 percent for Medicaid patients) increase in the price of the drug Daraprim by Martin Shkreli’s Turing pharmaceuticals.

Back of the envelope calculations indicate that Indiana could have been accountable for over $1.9 million in unexpected Medicaid costs in one year alone. This number is very variable based on how many of the newly diagnosed patients are low-income and eligible for Medicaid and how much the average cost for Medicaid HIV has increased since 2011, prior to the dramatic increase in drug costs. The number is expected to be much larger because of the relative wealth of Scott County, Indiana indicates a greater portion of those infected are likely to be Medicaid eligible and the cost for treatment has increased.

Regardless of the exact costs incurred, the spike in HIV infections in Indiana due to the opioid epidemic lead to increased costs to Medicaid.

How would this be different under the current Medicaid funding structure compared to the per-capita cap system? Under the current financing structure, the federal government would reimburse the state for over 65.5% of the cost of these new Medicaid costs, requiring the state to find the remaining portion. Had the per-capita cap program been implemented prior to this epidemic, Indiana would have had to bear the entire cost for this unexpected increase in funding. Because many states are not able to run deficits, the increase in costs would result the state either providing in fewer services or raising taxes.

How would Mike Pence have responded? His record as governor indicates that he would likely decide to reduce services. However, he learned from the response to the epidemic that small investments in public health programs (that often bear the brunt of these cuts) were able to effectively reduce the spread of disease. Additionally, he did recently promise that no one would “fall through the cracks” in Medicaid through the Republican’s health bill.

Mike Pence depended on federal funding when his state failed to prevent an epidemic. Per-capita caps would have been devastating for Indiana. Why would Pence push a policy that he would have likely opposed only a year ago?

Why are Conservatives Underplaying the Medicaid Reductions in the Affordable Care Act Repeal?

cutsA new argument has emerged in recent weeks in the debate over the repeal of the Affordable Care Act on the new policy to shift in the Medicaid payment system to “per-capita caps” or “block grants.” The argument is an attempt to portray the reductions in Medicaid enrollment and federal dollars allocated to the program as “hysteria” or dramatizations the reductions. The argument is recycled from the last eight years of the cuts to Medicare managed care plan incentive payments in the Obamacare debate, only with political parties switched.


The assertion from groups and pundits on the right who are in favor of the per-capita cap and block grant proposals is that the reductions in federal spending are not cuts to Medicaid.


From a purely logical perspective this makes little sense. The Congressional Budget Office has shown that the Medicaid program would see more than $800 billion in reduced funding and 14 million fewer eligible people would be enrolled than currently are in the program over the next ten years. The reality is that states will have to reduce the number of services they provide or reduce the types of people that can enroll as inflation and increased costs in medical services rise. This sounds like a cut. What the defenders of this claim- ranging from Karl Rove to Sally Pipes have insisted is that this is a cut to the growth rate, not cuts to the existing program.


But in a broader perspective this doesn’t follow a logical line from the conservative argument. The GOP has campaigned for decades on the idea that the social welfare state is bloated and that the oversized growth of the welfare state needs to be trimmed. The GOP should embrace the idea of calling per-capita caps and block grants cuts. From a policy perspective, the goal of the per-capita caps and block grants is to reduce the size and scope of the program.


Why have they begun to shy away from the argument that has been popular among their base and the broader public for decades? The most salient reason is that we have moved out of the Reagan era as the populace has moved to the left. The evidence for that lies with the popularity of Medicaid and the unpopularity of the Republican health care plan. The other reason proponents of the cuts have moved away from embracing their cuts is that Medicaid is efficient and trimming the program does not hold weight.


First, Medicaid is popular and the GOP American Health Care Act (AHCA) is not. In a recent poll by the Kaiser Family Foundation, Democrats and Republicans alike opposed cuts to the Medicaid expansion and half of Republicans oppose changing the existing Medicaid financing structure. Many other polls show that the majority of voters have favorable views of Medicaid, coming close to the level of support for Medicare. Telling is that a Quinnipiac poll found that Republicans oppose cuts to Medicaid. This is one possible reason that the latest messaging appears to be focused on reframing the cuts as minimal. Meanwhile, the AHCA has polled from 1721 percent by Quinnipiac and only 8 percent think that the Senate should pass these reforms without changes.


More importantly, the reality is that Medicaid is a pretty efficient program considering who it is providing services for and the types of care provided. Medicaid general spends less than other insurers to treat similar populations, largely because it often pays providers at a lower rate, although there is significant variation from provider to provider. The growth in Medicaid expenditure varies significantly from type of Medicaid coverage with the per-capita growth in long-term care much greater than the care for children, for example. In reality one of the largest causes of growth to Medicaid expenditures is the aging of the population with more people requiring long-term care services.

Pregnancy Services in Alabama

This week it was reported that many women in Alabama have to wait until the second trimester of their pregnancy before they are able to see a doctor for prenatal services. The wait is often caused by a delay in the bureaucratic process of determining eligibility. Before a woman is able to receive pre-natal treatment, many OBGYNs in the state require that a woman is enrolled in Medicaid. This causes many women to go without care until the state has approved their application. All states are required to process applications within 45 days. While Alabama does not provide a timeline of how long their application approval process takes, advocates have noticed that they often take longer than a month.


One major problem lies in how large of a problem this could be:

– Nearly 53 percent of births in Alabama are financed by Medicaid

– Only 75 percent of Alabaman mothers receive adequate prenatal care


While on average Alabama Medicaid asserts that 64 percent of Medicaid mothers receive prenatal care in the first trimester or within 42 days of enrollment, this doesn’t necessarily indicate that the level of care they are receiving is timely. If applicants aren’t approved for six weeks after their application this is already half way through their first trimester.


There may be an easy way to lessen Alabama’s problem.


The natural thought is that OBGYNs could accept Medicaid eligible patients while their application is under review by the state. However, this solution relies on the physician carrying the risk that the pregnancy will not be covered or that their patient would not apply for coverage, especially if there were a complex condition, requiring expensive treatment. While preventative service appointments that are at question here are low risk in terms of the financial stake of the patient not being eligible for Medicaid, the risk that OBGYNs may fear is that the patient would need sudden high cost treatment.


Since 1986, a policy known as presumptive eligibility has allowed states to enroll pregnant women in Medicaid through a seamless process. The goal of this policy is to allow pregnant women to get care while their application is under review.


Alabama is one of 19 states that have not extended presumptive eligibility to pregnant women. The policy is available to states to extend coverage to children and pregnant women across the state at all hospitals. A second more recent change to the policy has made presumptive eligibility available for hospitals to assume eligibility for all populations covered by the state’s Medicaid program. Prior to the passage of the Affordable Care Act, a hospital in Alabama that saw many pregnant women may not be reimbursed if a pregnant patient weren’t already enrolled in Medicaid. Now hospitals can elect to perform presumptive eligibility and presume low-income pregnant women would be eligible for Medicaid and provide seamless care.


Unsurprisingly, the American Health Care Act, that passed the GOP House contains a provision that ends the presumptive eligibility program. This provision has seen opposition from Republican governors in the past. To date there is little evidence that hospitals have taken up this policy in states or whether this policy leads to greater use or expense to states.


This is a policy with little research into its effect. But one possible impact could be that it influences the behavior of OBGYNs and could increase access to prenatal pregnancy services.


While most prenatal care is not provided in a hospital setting, it could ease the fears of OBGYNs that they would not be reimbursed for more costly care. OBGYNs affiliated with hospitals could ensure that patients have the attention and high quality care that necessary during pregnancy.


Hospitals in Alabama have the opportunity to reduce the problem created by the Alabama Medicaid agency’s failure to take up the 30 year old policy to provide care to pregnant women and the agency’s slow approval process. By hospitals enrolling in presumptive eligibility there is a chance that more women could see prenatal care and healthier babies will be born in Alabama.

In defense of the ending of La La Land


The ending of La La Land reinvigorated my faith in humanity and helped me recover from the election.


With the Academy Awards this weekend you really have no excuses not to have seen La La Land yet. The presumptive best picture award winner captivated many viewers with the simple fact that in the face of all of the news and reality the country has been facing– it was fun.


I should note that I have seen almost all of the nominated pictures and preferred Lion and Hidden Figures but also appreciated the beauty of Moonlight. However, I credit La La Land with impacting my life more than many movies I’ve seen in recent years.


Like many, the election made me sad. I love our country and watching it go in a direction that I don’t agree with is sad.


November and December was one of the worst periods for my mental health, not only because of the election, but because of financial, personal, existential, and romantic downturns. It was in that state of mind that I went to see La La Land with my parents for our annual Christmas Day movie.



In the ending of La La Land, the two main characters break up and end up achieving all of their dreams, he to open a music club and she to become a famous actress. At the end of the film, there is a brief flashback that almost makes you feel like it is an alternative ending, completely changing much of the plot of the movie. In the flashback simply the meet-cute was slightly altered and the rest was history as the two stayed together. The flashback ends and we are brought back to the reality that they were not together and their lives continued.


Walking out of the movie theater I overheard many people commenting that it was a good movie “but the ending! They should have ended up together.” No, they shouldn’t have. That’s not the way life works.


Sometimes life is sad. Sometimes what you thought would be happy and perfect doesn’t work out. Actually, that’s what usually happens. While the characters may have been perfect for each other because they were both played by talented actors and we were meant to be cheering on their romance for the previous two hours, life is complicated and flawed. While two people can want the best for each other, they may not always be best for each other. Heartache and failure are necessary for rebuilding one’s life and building character and resilience.


In a world where I seem to constantly be surrounded by people and thinking that we cannot admit we are sometimes wrong (example a: American contemporary politics) and an artistic medium where life always needs to end up wrapped in a tidy bow, it was refreshing to watch the movie continue to show the “what could be” scene. Life is full of the “what could be’s” and while it is important to take time at jazz clubs to reflect on how your future could have changed, even more, important it is paramount to reflect on the success you’ve achieved alone as a result of the experience that is life.


This is why I loved La La Land, not from the dancing and singing (I loved that too) but from the reminder of resilience.

The problem with the NBER paper on Medicaid reducing divorce

This week David Slusky and Donna Ginther released an NBER working paper which strongly suggested that Medicaid expansion reduced the prevalence of divorce by 5.6% among those aged 50-64. Their thinking is this- prior to the passage of the Affordable Care Act, the only way that many middle-income adults could qualify for Medicaid coverage was to spend down their assets to become eligible for one of Medicaid’s eligibility groups. Many people engaged in what is known as “medical divorce” when one spouse would become ill and need Medicaid services (particularly for long-term care services that Medicare does not cover). The couple would divorce so that the assets of the sick spouse would qualify them for the Medicaid asset test (often around $2,000 for an individual and $3,000 for a couple). Medicaid expansion allows all people regardless of assets apply for Medicaid coverage so long as their income is below 138 percent of poverty. Using a difference-in-difference approach comparing states that expanded Medicaid eligibility to 138% of the poverty level to states that did not expand, the authors found that divorce rates were lower in expansion states.

The problem with this paper is that Medicaid expansion did not entirely get rid of the asset test.

Medicaid is not one program. There are many avenues that a person can get Medicaid and the benefits and structure of that program look different for each eligibility group. Broadly speaking we can qualify Medicaid eligibility into MAGI and non-MAGI eligibility. The Affordable Care Act requires all states to use the Modified Adjusted Gross Income (MAGI) to calculate the eligibility for certain types of applicants (pregnant women, children, and the newly eligible Medicaid expansion adult population). These populations receive benefits that similar to private health insurance – hospital services, doctor services, and pharmaceutical drugs. They do not receive Medicaid long-term care services. There are certain groups that are exempt from MAGI eligibility (referred to as non-MAGI). These are Medicaid programs for the blind, disabled, and those over 65. These groups receive long-term care services. This is the population that typically engaging in medical divorces because private insurance and Medicare does not cover long-term care and Medicaid is the primary payer for long-term care services. Without Medicaid, people often pay up to $60,000-$80,000 annually for long-term care services which could impoverish families.

Yes, there could be some people that are early retirees or elderly couples that might need cancer care or other expensive hospital procedures and would qualify for Medicaid expansion rather than private insurance without the asset tests, but these are rare cases of people forgoing private insurance for the Medicaid medical safety net. Although high deductibles can be unaffordable for many, it is rarely the cause for divorce.

The paper does not look at divorce rates for populations over the age of 65 in states that have expanded versus those that did not expand. This might provide a more complete picture since the population over 65 is often the people who would divorce because of Medicaid asset test eligibility. If the rates similarly have gone down, perhaps there are other factors other than Medicaid expansion causing rates to fall.

Asset tests are prominent in Medicaid long-term care programs. In California, the asset test for a couple to qualify for Medicaid disability coverage was $3,000. California has not increased that amount in nearly 30 years. The value of that asset has halved since it was put into place in 1989. We haven’t eliminated asset testing and by believing they aren’t a problem we have made them worse because they have reduced in value. I wrote a longer explanation of the problem here.

The financial security that Medicaid provides does have large scale effects. Financial insecurity is a leading cause of divorce in the US and it is conceivable that more financially secure people because of the safety net of Medicaid expansion are less likely to divorce. However, reduced medical divorce to avoid asset tests is not happening because asset tests are alive and well in this country. I suggest that this may be the mechanism for the reduced divorce rates in those states. Alternatively there are many other causal factors that could be reducing divorce but asset limits are unrelated.

Where I am right now.

A few days ago I ran into a friend who I have had two conversations with prior to seeing her again on the street. She told me, “I’ve been thinking a lot about you over the last few days. All of the feelings of sadness that I have, I just envision that you are experiencing them 10 fold.”

Ladies, get out of spin class and on a bike

I ride two bicycles, one for commuting and one for happiness (going fast). Sometimes when I’m on my bike I get sad. I know, I said I have a bike for happiness, and trust me it makes me unbelievably happy.

But when I’m out riding the trails and going fast, I rarely see women on bikes. On a typical day I’ll pass dozens of  men with fancy bikes and riding gear “going fast” (let’s face it, I leave all of them in my dust). But I rarely see women out riding. In fact, I often get looks of confusion or maybe pride from men out riding. One time, when I passed a group of male riders, one said “oh hell no, we can’t let a girl beat us.” It’s so rare to see women on the trail that it seems foreign, even in Massachusetts.

Cycling requires some high up front costs and yes, it can be dangerous. I’ve gotten hit 3 times and have the scars and bruises to prove it. But I also have tripped running a dozen times and have the scars to prove that as well. My knees are basically scar tissue.

When I go to spin classes they are usually 60-80% female. So I know women know and enjoy riding.

There is something magical about the wind in your hair and the sun shining down on your face. Boston has some beautiful trails and it takes about 5 minutes to get from the bustling city to nature.

I’m really only writing this to remind myself how much I love cycling and how much of a badass it makes me feel like for the next time I’m lying on my bed too lazy to hit the trails.