Medicaid Eligibility Expansion

Governor Rick Perry wants to reject Obamacare's expansion of Medicaid eligibility. A majority in the legislature apparently agree, mostly on financial grounds. Probably a majority of voters do too. The Texas Catholic Conference, a number of other groups, and most of my friends in the social justice advocacy community want them to reconsider.

I think expansion is a bad idea. It will make a bad situation worse. For years Medicaid officials have been controlling costs by holding down payments to providers. The result is fewer and fewer doctors will accept new Medicaid patients. It is almost impossible to find one in Collin County. If you have Medicaid and need a doctor you will most likely have to look elsewhere, if you can find one at all. If we add millions more poor and near poor Texans to the program we can expect it to cease functioning altogether.

Obamacare purports to address this by temporarily raising payment rates to Medicare levels. Then after two years price controls resume. It is less than reassuring to look at what is happening in Medicare. The government has been trying to control payment rates there as well. As we might guess doctors are threatening to leave that system too. Congress has to pass the so called "doc fix" every year to prevent a mass exodus. Expansion proponents, if they are thinking about this at all, appear to be reasoning that it they can get enough voters enrolled in Medicaid they will force  congress to include them in the annual fix. This year's doc fix threatens to become lost in the overwhelming financial crisis so dominating the current news. It is a frightening prospect.

Let me stipulate something. I believe access to basic health care is a fundamental human right. We are morally obligated to see to it that no child dies of a brain infection because he couldn't get treatment for a toothache. We can prevent that and we should. But that doesn't extend to the right to heart transplants at public expense for nonagenarians.There is a place for triage within our ethical universe, and a place for palliative care.

There are some promising ideas out there, and room within the current system to implement some of them. Florida started a pilot premium support program six years ago in five large counties that gave recipients a choice from a variety of plans offered by insurance companies. By all reports costs went down, outcomes improved, consumer satisfaction went up, and provider participation is higher. Florida wants to expand the program statewide (it requires a waiver from the Feds) and Louisiana is looking at trying something similar.

Texas has something called STAR Medicaid that is a state wide alternative to traditional Medicare, available for some patients, required for others. It sounds somewhat similar to the Florida pilot but if it has had the kind of success claimed in Florida I don't see it in the news. Former Governor Jeb Bush is touting his plan as a Medicare Cure. I would like to know more about it. Maybe now that the election is over we can get a little breathing room from the demagoguery and entertain some serious discussion. Or maybe not. The headlines aren't encouraging.

Texas has among the most restrictive eligibility requirements in the country. Unless you are a child, disabled, or elderly you are almost certainly not eligible for Medicaid. I would like to see better access to health care for more people but the solution currently on the table doesn't look workable. If we could get costs under control I might be able to support it. Maybe others could too. I hope Jeb Bush gets a hearing.