It’s imperfect but if you’re interested in a pretty fair introduction to the enormously complicated Medicaid system, this piece at The American Interest by physician Mark Hammer is not a bad start. Here’s its conclusion:
Without thoughtful reform, Medicaid will ultimately be forced to decrease the number of its beneficiaries, decrease services covered, and shift more costs to enrollees and the private sector. In desperation the Trump Administration has already begun doing many of these things to the extent permitted by administrative discretion. It won’t be enough.
Over the last 40 years Medicaid spending has increased 5-fold in real terms, faster than health care spending overall. That’s mostly the result of higher prices and mission creep. Some of the mission creep was an intentional feature of the Affordable Care Act.
Medicaid’s spending will grow rapidly for the foreseeable future. Many people aren’t aware of it but Medicare doesn’t cover nursing home care. Nearly 2/3s of those in assisted living or skilled nursing facilities are having the bill paid through the Medicaid system. Most of those people are people who made decent incomes while they were working but through various strategies, dodges, and so on manage to inveigle themselves into the Medicaid system. As the Baby Boomer retire, age, and die, something that is happening at an accelerating rate, so higher Medicaid spending is inevitable.
And Medicaid is killing the states. Here in Illinois, for example, Medicaid accounts for about a third of total state spending. Medicaid, public employee salaries, and public employee pensions are the three biggest line items in the state budget here and they’re all growing rapidly even as the state’s population is declining.
I don’t know if reorganization, the cost control measure proposed in the piece, could be effective. I do know that Medicaid’s enormous complexity and the breadth of services it includes are among the reasons I’m skeptical of the practicality of the “Medicare for All” that’s becoming a litmus test for Democratic office-seekers.
This is not about the advisability of such a program; but an entitlement to elder care would be immensely popular; more so then Medicare for all.
The stories about what people do to get elder care are pretty heart wrenching.
We need to decide what sort of country we’re going to be. Historically, families then churches have provided for the elderly. Is it possible for most people to provide for themselves in their old age? I’m skeptical.
If we’re to be a country in which the government takes care of people when they’re too old or sick to work, we’re going to be a very different country than we have been. I think that would take more social cohesion than we can muster and require most deference to authority than has been thought proper.
We should always be suspicious when someone resorts to the waste fraud and abuse argument, especially when he does not substantiate his claim. I don’t know where he comes up with the idea that the increase in spending is driven by an increase in costs. It is mostly enrollments. Again, it would be nice if he substantiated anything. I also don’t know why he thinks resorting to private insurance will help since it is nearly always more expensive. Anyway, KFF has made an effort to provide us with some numbers.
https://www.kff.org/report-section/medicaid-spending-growth-compared-to-other-payers-issue-brief/
Even though I think many if not most of his numbers are wrong, I don’t think that separating out elder care is such a bad idea. It is something we just ignore, and everything we ignore gets sent to Medicaid. My best guess, since the old folks actually vote, is that this increases overall medical spending, but what do I know.
Steve
I think that’s just about right.
The key point is that health care costs are growing faster than GDP or incomes. That’s obviously unsustainable and the reason why they are growing matters more to how we construct a solution that to whether we construct a solution. The longer we delay in deciding there’s a limit to how much we can spend on health are the worse it will be for the poor. IMO that’s a good place to start.
We never actually had to put my mother’s hospice care on medicaid, she had enough for the nine weeks it took, but we had to plan. Assets had to be drawn down to $2,000.00, SSI would be drawn down to $50.00/Mo.
Any asset transfer had a lookback window of 5 years. This is Ne. , Ia. is even tougher, they look at total assets of Medicaid recipients children with no limit to the lookback window, but with a reasonable asset limit.
Money has to come from somewhere.
In my humble opinion, the problem is that modern medicine can extend life past living. It can’t be funded, and we have nothing to fear but fear itself.
Again, living wills.
“IMO that’s a good place to start.”
Not so sure. Reimbursement by Medicaid is generally the lowest of the three broad areas (Medicare, Private insurance, Medicaid). Cutting reimbursements even more could just as easily reduce coverage. The real reason to start with Medicaid is that it generally covers the people who are unable to fight back.
Steve
Sadly, as with everything relating to Medicaid it’s more complicated than that. I really haven’t looked into it in any detail but my intuition is that the fastest-growing components of federal and state health care spending are hospital reimbursement and nursing home care. Since one of Medicaid’s many programs is one to reimburse hospitals for the difference between Medicaid and Medicare reimbursement rates, there is not as much sharp distinction between Medicare and Medicaid hospital reimbursement rates as might otherwise be the case. And nursing home care is purely a Medicaid issue.
Nursing home care is hugely expensive. For my mother – and this ten years ago – she lived at home with some home assistance until she broke her hip. After a short hospital stay, it was something like $2500 a month (paid for by Medicare) for a place that basically did nothing except put her in a bed and wait for her to die. We eventually, after a lot of work, got her transferred into a skilled nursing rehab facility at our own expense and that was double the price. But by then it was too late, she only lasted a couple of weeks.
Now we are facing an issue of what to do with my sister, who has had quite sudden progression of dementia over the last year. The MRI shows ischemic white matter disease and significant brain volume loss. She is only 65 and is otherwise in excellent health. Her assets are minimal. One of the reasons I moved back to Colorado was to assist with her care, whatever it will be. Given my mother’s experience, I’m confident we can’t afford care at a good memory unit, so she will probably end up living with us. In my area, a nursing home runs $5-7k a month and even an assisted living facility is over $50k a year.
In short, there are no easy answers. The normal American default position seems to be to institutionalize people using Medicare or Medicaid. That is certainly what every doctor I’ve ever encountered has recommended.