Medicaid Expansion and the Trust Issue

Ye olde bait and switch.

Ye olde bait and switch

by James A. Bacon

Do you trust the federal government to make good on its promises to uphold entitlement spending? Or do you fear that, as the federal funding crisis intensifies, the feds will renege? That is the question at the heart of the debate over Medicaid expansion in Virginia.

Bart Hinkle, a columnist for the Times-Dispatch, invites readers to consider the fate of the American Indians who put their faith in federal promises. Years ago the Bureau of Indian Affairs and the Indian Health Service contracted to provide medical services to reservations across the country, only to break their commitment. Health care services have been disrupted as a result. The tribes sued for breach of contract, the U.S. Supreme Court backed them up a year ago and, yet, the Obama administration has yet to redress the breach. It appears there is not enough money to go around. Hinkle extrapolates to the Medicaid debate:

Current estimates say the federal government’s share of the tab for Medicaid expansion from 2014 through 2022 will come to $931 billion. If the cost is lowballed to even a small degree, then the feds will see more than $1 trillion in new expenses over the next decade.

By contrast, the federal government owes Indian tribes a comparatively paltry $2 billion or so. And that obligation is not merely statutory, but contractual. Yet even after Supreme Court intervention, Washington refuses to cough up the dough. …

If the federal government can ignore its contractual obligations, its own statutes and its own Supreme Court, then it certainly can ignore its own funding formulas, too. This doesn’t necessarily clinch the case against Medicaid expansion; it’s just one point among many. But it does suggest those hawking the promise of free federal money epitomize Samuel Johnson’s definition of second marriages: “the triumph of hope over experience.”

One day, historians will look back upon this time and be amazed and appalled that Americans decided to expand Medicaid entitlements while ignoring the eroding foundations of Medicare and Social Security.

The Disability Insurance (DI) trust fund within the Social Security program will run out of money in 2016 — two years from now! — meaning either that benefits for millions of disabled Americans will be cut by 20% or that money will have to be taken from some other source, most likely from the Old Age Survivors Insurance (OASI) fund.

OASI is scheduled to run out in 2035. If Congress resorts to the craven and cowardly expedient of kicking the can down the road by tapping OASI to prop up disability payments, then both programs will run out of money by 2033.

Meanwhile, Medicare’s Hospital Insurance (HI) reserve is scheduled to run dry by 2026. That represents an improvement from last year when the Social Security and Medicare trustees projected that it would run out in 2024 based on the conviction that cost-control measures embedded in the Affordable Care Act would stretch the Medicare trust fund a bit further. You can choose to believe that logic if you wish, even though Medicare’s own chief actuary took the extraordinary step of publicly disagreeing. But even under the more optimistic premise, a Medicare financing crisis is only twelve years away.

So, imagine it’s a decade from now: 2024. The Medicare trust fund is either evaporating or two years from doing so, portending a massive financing crisis for America’s second-largest entitlement program. Panic! The impending Social Security funding crisis is now only nine years away, too close to ignore. Blind panic! Another $6.3 trillion in budget deficits (CBO forecast) has brought the national debt to more than $23 trillion. Interest payments on the debt now amount to $900 billion a year, meaning that a huge chunk of the federal government’s cost structure is not subject to budget cutting. Outright hysteria!

Against that backdrop, federal Medicaid expenditures will have soared from $298 billion in FY 2014 to about $580 billion in FY 2024. Can anyone assert with a straight face that a future Congress might not try to spread the pain by insisting that the states pay a greater share for the expanded Medicaid program? It would take a blind faith in the goodness of the federal government to deny such a possibility. I have no such faith. Expanding Virginia’s Medicaid program will make the Commonwealth vulnerable to a bait-and-switch a decade from now. Restructuring Virginia’s health care system around a bigger Medicaid program invites the same fate as the Indian reservations. No thanks.

18 Responses to Medicaid Expansion and the Trust Issue

  1. the “trust” issue is a flimsy excuse to not only not take action on the Federal aspect of MedicAid but to also not take action on the State part of it.

    In terms of breaking promises… how many on Social Security have had their benefits reneged on? How about Medicare? How many Federal and Military retirees have had their benefits reneged on?

    then we have characterizations of SSI and HI “running out of money.. running “dry” which is patently false.

    the money to pay SSI and HI will continue to be there.. it will not be “exhausted”.

    what will happen if that there won’t be enough money to pay 100% of benefits and by law, if no changes are made, benefits will reduce – gradually over decades… rather than the idea that all benefits will stop on those dates where it is aid that they will “run dry”.

    it’s wrong in my view to characterize in that way because it’s deceptive and leads people to conclusions that are not what will happen.

    It’s a technique characterized by those on the right who want to promote the idea that these programs will run out of money and be “broke”.

    and it’s not true.

    re: ” Against that backdrop, federal Medicaid expenditures will have soared from $298 billion in FY 2014 to about $580 billion in FY 2024″

    what other expenditures – like those for the Military and the Military retirement and health care would you also predict?

    how about the highway trust fund? how about the military presence in Va?
    do you want to refuse Federal Highway dollars …Federal education dollars, Military dollars in Va using the same premise?

    using the “unknown” of the future as an excuse to do nothing now even on things that Va can do without involvement of the Feds is an example of the bankrupt, refuse-to-govern attitudes of the “right” these days. It was not a characteristic of the GOP I used to know.. who would be responsible about the present even as they addressed the challenges of the future.

    I note that Vermont and Massachusetts took on their own states health care needs without the Feds and that other states are taking MedicAid money right now to build their own state-based systems that they will manage in the future no matter what happens to MedicAid.

    this is more proof of the irresponsibility of the GOP these days…. in my humble opinion – using excuses to explain why they cannot deal with
    solutions.

    shame.

    • Larry says, “Then we have characterizations of SSI and HI ‘running out of money.. running ‘dry’ which is patently false.”

      Larry is patently mischaracterizing my statement. I did not say that the programs were running out of money, I said the *reserves* were running out of money, quoting directly from the Social Security and Medicare trustees’ annual report. As long as there is a payroll tax, the programs will be able to cover 75% to 80% of current expenditures, even when the reserves run out. But a 25% cut to Social Security and Medicare spending patently will constitute a fiscal crisis.

      • re: ” Larry is patently mischaracterizing my statement. I did not say that the programs were running out of money, I said the *reserves* were running out of money, quoting directly from the Social Security and Medicare trustees’ annual report. As long as there is a payroll tax, the programs will be able to cover 75% to 80% of current expenditures, even when the reserves run out. But a 25% cut to Social Security and Medicare spending patently will constitute a fiscal crisis.”

        when the narrative contains multiple references to “running out of money” – and you are not crystal clear about what that means and what it does not mean – it borders on misleading when other words like “going broke” are used.

        as I said – SS, SSD, and HI are gnats on a dogs butt fiscally compared to Medicare Part B , Part C and MedicAid reimbursement of nursing homes for people who own homes.

        People can still live on 75% of scheduled benefits – on a worst case, no fixes basis, if that becomes the reality. It won’t be fun but they won’t be living in cardboard boxes and eating out of dumpsters.

        but continuing to hammer on SS,SSD and HI while ignoring the problems with Medicare Part B and C and Medicaid nursing home costs is not accurately characterizing the overall entitlement problems.

        it cherry-picks the minor problem to elevate it as “going broke” while totally ignoring the real entitlement issue which is selling govt subsidized full-coverage insurance to people making 170K in retirement income for 100.00 a month.

        that’s a real problem. it’s the one we should be talking about.

        if we fixed that problem, we’d have enough money to fix the SS and MedicAid issues…

        My attitude is as a fiscal conservative… My view is that we’re not going to get rid of these programs .. that idea is a right-wing wet dream that is not going to happen.

        Our choice is to make these programs more fiscally sustainable and that means – at the front – stop subsidizing people who don’t need the subsidy.

        if you do that – you may well have enough money to pay for the other things.. or at least a start towards that.

        from my viewpoint, it appears that we simply do not want to truly deal with the issues.. and instead we want to continue this wrong-headed right-wing narrative about how “wrong” entitlements are for the poor ..

        and we have that conversation at the same time we are defending subsidies for people who don’t need them…and should not be getting them.

        I mean this in all due respect despite my passion… for the issue.

        I’m a pragmatist. We need to address the issues and stop this partisan and ideological foolishness.

  2. re: ” … The Medicare trust fund is either evaporating or two years from doing so,”

    this is wrong – not once but TWICE!

    1. the Medicare “trust fund” is for Medicare Part A – ONLY – not Part B.

    Part A is hospitalization while Part B pays for doctors/providers.

    there is no “trust fund” for Part B… none… at all.. it’s purely a subsidized fee-for-service – voluntary program that no one paid a penny into .

    but the “trust fund” for Part A is not it’s primary funding… that comes from FICA taxes… the trust fund itself is a small fund that is being used to make up the current funding gap from FICA and when the trust fund “exhausts” – FICA taxes will continue to pay for Medicare Part A – but at a reducing level. Medicare Part A will not cease to pay benefits.. but they will reduce.

    we would, in fact, be better off if all of our Federal programs operated on that basis – that they get what the revenues bring in – and that’s all they can spend.

    The 600lb fiscal gorilla in entitlements is NOT social security nor social security disability or HI – it’s Medicare Part B and C (gap coverage).

    right now – we provide guaranteed insurance with no lifetime gaps to seniors 65 and over who can make 175K married and still only get charged 100.00 a month for health care.

    think about that..

    how many people do you know under the age of 65 who can buy guaranteed health insurance with no lifetime caps for 100.00 a month?

    and yet those on the right want to talk about SS and Medicare Part A and SSD “going broke”.

    it’s not only propaganda.. it’s patently wrong to boot.. and it hides the real issues because the right wants to try to kill entitlements all together with it’s steady “we’re all going to go broke and die” drumbeat,,, .. but not one of them will advocate getting rid of EMTALA or tax-free employer-provided tax benefits.

    you cannot govern like this. it’s a dead-end that simply lives is LA LA Land and refuses to deal with realities…

    we fret about “going broke” over healthcare while every other OECD country on the planet covers all of their people for 1/2 what we spend in total to not cover everyone.

    it’s dumb.

    it’s ideology for ideology sake run amok.

    • Larry, in my post, I specifically stated that it is the Hospital Insurance portion of Medicare whose reserve is running out of money. Also, I specifically stated that it was the *reserve* running out of money. So, far from being wrong twice, I was correct on both accounts. You are throwing sand in the eyes of readers in the expectation that they did not read my post carefully enough to refute you.

      • but Jim.. it’s not “running out of money” in the sense that there will be no money at all.. on those dates.

        it is a misrepresentation to say that .

        As long as FICA taxes are collected, there will be significant money generated for HI… but it won’t be enough to pay 100% of scheduled benefits but it will be enough to pay about 75% of scheduled benefits.

        changes made may well include higher co-pays or other adjustments – like you might see with private insurance.

        the narrative that it will “run out of money” is misleading.

        it will NEVER run out of money unless FICA is done away with.

        that’s never made clear. the implication is that it will “run out of money”.

        that’s a disservice to the issue and to things that might need to be done..

        respectfully…

        • But Larry, I never implied that the programs would *totally* run out of money. In the context of Disability Insurance, I specifically stated that payroll tax revenues would continue the program at an 80 level. I can’t help it if people interpret my words through the lens of their own preconceptions.

          • re: ” But Larry, I never implied that the programs would *totally* run out of money. In the context of Disability Insurance, I specifically stated that payroll tax revenues would continue the program at an 80 level. I can’t help it if people interpret my words through the lens of their own preconceptions.”

            let’s go back over it:

            “Do you trust the federal government to make good on its promises to uphold entitlement spending? Or do you fear that, as the federal funding crisis intensifies, the feds will renege? That is the question at the heart of the debate over Medicaid expansion in Virginia.”

            what did you mean with this in the context of SS, SSD and HI?
            what are you implying ?

            “Bart Hinkle, a columnist for the Times-Dispatch, invites readers to consider the fate of the American Indians who put their faith in federal promises.”

            again.. what are you implying here?

            ” It appears there is not enough money to go around. Hinkle extrapolates to the Medicaid debate:

            Current estimates say the federal government’s share of the tab for Medicaid expansion from 2014 through 2022 will come to $931 billion. If the cost is lowballed to even a small degree, then the feds will see more than $1 trillion in new expenses over the next decade.”

            fair point.

            “If the federal government can ignore its contractual obligations, its own statutes and its own Supreme Court, then it certainly can ignore its own funding formulas, too. ”

            do you mean like mortgage deductions, Medicare premiums, flood insurance?

            One day, historians will look back upon this time and be amazed and appalled that Americans decided to expand Medicaid entitlements while ignoring the eroding foundations of Medicare and Social Security.

            then you cross over the Rubicon …. by comparing MedicAid – which is funded from general revenues to SS which is funded from FICA.

            “The Disability Insurance (DI) trust fund within the Social Security program will run out of money in 2016 — two years from now!”

            right here Jim .. you say it “run out of money”.

            ” — meaning either that benefits for millions of disabled Americans will be cut by 20% or that money will have to be taken from some other source, most likely from the Old Age Survivors Insurance (OASI) fund.”

            where did you get this from? why would the SS not limit SSD to what the FICA portion of SSD brings in – per the current plan?

            this is part of the gloom and doom narrative here.. where we start with facts and then start talking hypotheticals – as if they are preordained when they are not.
            this is the kind of thing you hear from the right wing think tanks.. it’s blatant propaganda.. and really misinformation…

            “OASI is scheduled to run out in 2035. ”

            AND you say it AGAIN!

            “If Congress resorts to the craven and cowardly expedient of kicking the can down the road by tapping OASI to prop up disability payments, then both programs will run out of money by 2033.”

            AND AGAIN!!!

            please explain … Jim.. what did you mean when you said “run out of money”?

            shame. shame.

  3. Larry, draw us a roadmap to get from where we are today to where every other OECD country is today – covering all there people for 1/2 of what the U.S. spends without covering everyone. Who wins and who loses? What has to be done to the losers to make them compliant? Without this map, aren’t we living in the world of the WaPo editorial board — LA LA Land?

    The biggest problem with the state budget is the growth of Medicaid costs, according to what I heard yesterday at meeting of the Fairfax County legislative delegation. As you have noted, a good part of that is nursing home care. Do you think the delegation (dominated by Ds) will introduce a bill to require sales of a recipient’s home or the taking of a reverse mortgage? I don’t.

    But the growth is also fueled by illegitimate births, according to what I heard yesterday. I don’t think we’ve debated this. And, I submit that, with expansion of Medicaid sans any major reforms, we’ll see a lot more growth in costs as Oregon saw with its experiment in expanding Medicaid coverage.

    Finally, what do you think McAuliffe will say in his first remarks about Medicaid? I think he will put on his blinders and make some lame remarks about expanding with free federal dollars. But I am more than ready to be proven wrong.

    • “Larry, draw us a roadmap to get from where we are today to where every other OECD country is today – covering all there people for 1/2 of what the U.S. spends without covering everyone. Who wins and who loses? What has to be done to the losers to make them compliant? Without this map, aren’t we living in the world of the WaPo editorial board — LA LA Land?”

      well TMT, … FIRST – you HAVE to WANT that roadmap guy instead of saying it cannot be done.

      ObamaCare is one potential path – that will need additional changes to get there but where are the better ideas? they are AWOL.

      “The biggest problem with the state budget is the growth of Medicaid costs, according to what I heard yesterday at meeting of the Fairfax County legislative delegation. As you have noted, a good part of that is nursing home care. Do you think the delegation (dominated by Ds) will introduce a bill to require sales of a recipient’s home or the taking of a reverse mortgage? I don’t.”

      Do you think McDonnell might have addressed it like he did the pensions and transportation but not MedicAid?

      you want Dems to address it in terms of eviscerating it while the Dems want it retained but reformed. Where is the reform proposal from the GOP that the Dems could sign on to?

      “But the growth is also fueled by illegitimate births, according to what I heard yesterday. I don’t think we’ve debated this. And, I submit that, with expansion of Medicaid sans any major reforms, we’ll see a lot more growth in costs as Oregon saw with its experiment in expanding Medicaid coverage.”

      do you want to deny Medical care to people who have kids illegitimately?
      If you do not.. what is your solution?

      Start first by requiring people with assets to not get Medicaid then let’s discuss whether illegitimate births are going up or down? but the real question is would you deal with the problem by cutting off MedicAid to those who are having kids? If you’re not willing to cut the aid then why are you bringing it up as an issue? If you bring it up – then tell me what to do about it or else it’s going to sound like you won’t deal with it but want it as an excuse to do nothing. we have too much of that already.

      “Finally, what do you think McAuliffe will say in his first remarks about Medicaid? I think he will put on his blinders and make some lame remarks about expanding with free federal dollars. But I am more than ready to be proven wrong.”

      My question back to you is why are you presupposing what the man will do ?

      My second question to you – is – if the General Assembly had already tackled this and began the process – would McAuliffe try to dismantle what they did because he disagreed?

      The States determine the eligibility of MedicAid.

      Do you know what that means?

      it means if the Feds renege on the dollars that Va tightens up and restricts eligibility to be consistent with reduced available funding.

      why is there an excuse to do nothing because of something you don’t know will happen but in any case – you have clear options to deal with it if it does happen?

      this is just more excuses to do nothing.. it’s feckless non-leadership.

      this is an opportunity for Virginia to put together a more efficient and more cost effective system for the poor… even if the dollars go away later..

      we could use the dollars for as long as they lasted to build up our own system of clinics and physician assistants, etc… but instead because of partisan politics and just dumb ideology – we refuse to act.

      there is no excuse for it. people should be ashamed.

      • Larry, you are simply dodging the question. What do you see as a roadmap from we are today to where other OECD nations are and how do the feds use their coercive power to make the losers comply?

        How do we get a hold of Medicaid costs? I’ll give you the nursing home issue. But what about the rest? How do we cut the costs? Let anyone do anything he/she wants and society must pay the costs. It’s for the children. How about at least imposing a $5 copay?

        And watch McAuliffe will call for expansion without cost reductions. He’s going to dance with those who brung him.

        • “Larry, you are simply dodging the question. What do you see as a roadmap from we are today to where other OECD nations are and how do the feds use their coercive power to make the losers comply?”

          Our roadmap is to START and use Massachusetts, or Vermont, or Oregon or Kentucky as models.

          the idea is not to accomplish it all right away but to put in place an incremental approach – starting with expanding MedicAid like those other states have.

          “How do we get a hold of Medicaid costs?” by getting people into primary care and away from ER care… and by paying for outcomes not diagnostic codes… and by doing what the VA does -negotiate for drugs. There are dozens of ways of STARTING THIS… instead of finding excuses to not.

          “I’ll give you the nursing home issue. But what about the rest? How do we cut the costs? Let anyone do anything he/she wants and society must pay the costs. It’s for the children. How about at least imposing a $5 copay?”

          I totally agree with the co-pay and means-testing.. and community clinics using Physician Assistants and Nurse practitioners.

          “And watch McAuliffe will call for expansion without cost reductions. He’s going to dance with those who brung him.”

          but why focus on him instead of doing something to essentially preempt him from the start? why do nothing then wait him to do what you donj’t want? this is what happens when you don’t lead…

          the GA has an opportunity to lead – instead of waiting to pounce on McAuliffe… for what they don’t agree with.

          It’s dumb to not take the expansion and use it to build a Va-based clinic system that will get people out of the ERs and into routine care even if that care is primarily given by Physician Assistants and other para-medical people – which by the way would be jobs for Virginia’s youngsters… growing up.

          • Massachusetts has broad coverage but much higher health care expenditures. How is that a road map to lower costs – the carrot that Obama offered? Oregon’s Medicaid experiment proved the prediction of more primary care and less ER care wrong. Expenditures are up. How is that consistent with the Obama promises? The typical liberal answer is: Just trust us. We care and deep in our hearts we know we are right.

            The only offensive fiscal in a liberal world is the failure to give enough of one’s money to the government. What about results? Before McAuliffe utters a word about Medicaid expansion, he should address the Oregon situation. How can he ensure we won’t see a similar failure?

            I’m not opposed to incremental progress. But we have strong evidence that Medicaid expansion is more costly. We have strong evidence that the Massachusetts approach is more costly. It looks to me that one more of the Obama premises for health care reform is simply wrong and that his approach will fail. But your view is that failure is better than the status quo. So what if millions lose their insurance; have to pay higher premiums; have higher deductibles; lose access to their existing doctors. Because the GOP didn’t have a substitute bill, Obama’s great failure must stand. This is a crock.

            The ACA is probably the worst piece of legislation in the history of the United States. It produces very little of the proffered benefits, but most the defects that we were assured won’t happen. The idea that Obama would accept modifications (not repeal) is bogus. The House passed a bill that would have grandfathered existing policies – ala “If you like what you have, you can keep it,” but Reid will not allow it to come to a vote in the Senate. There is no reform. It’s continue to harm the nation with the ACA or try to get rid of the law. You try to destroy cancer, not protect it unless the cancer is the ACA.

  4. Long term we’re screwed. I do not expect the promises made to me with regard to Social Security or Medicare (and I’ve paid the taxes since high school summer jobs, some years the max) to be kept. People like me who have saved and invested and have not taken European vacations or bought a car fancier than a Camry, who have avoided debt, us frugal savers will be told — YOU’RE TOO RICH. YOU DON’T GET IT AFTER ALL. (It’s only fair….) These social insurance schemes are not Ponzi schemes per se, but they do depend on population and prosperity growth and we just may not have enough coming in to keep the promises to pay out.

    Now Medicaid on the other hand is welfare, pure and simple. Our tax dollars pay for Medicaid, and our tax dollars will continue to pay for Medicaid whether Virginia expands the coverage or not. To pay the taxes and turn down the benefits is dumb, dumb, dumb. Just make it clear that when the fed’s break their promise (as they will have to) Virginia will dump out of the program.

    • “Long term we’re screwed. I do not expect the promises made to me with regard to Social Security or Medicare (and I’ve paid the taxes since high school summer jobs, some years the max) to be kept. ”

      As long as FICA taxes are collected -you’ll get at least 75% of planned.

      but the question is with regard to Medicare – Part B … since you have not paid into it- what do you think you should pay for it?

      do you called “screwed” .. getting guaranteed health care without lifetime maximum for 100.00 a month – “screwed”? How about if you paid $500 a month – which would make it a self-supporting program? Would that be “screwed”?

      “People like me who have saved and invested and have not taken European vacations or bought a car fancier than a Camry, who have avoided debt, us frugal savers will be told — YOU’RE TOO RICH. YOU DON’T GET IT AFTER ALL. (It’s only fair….) ”

      People like you – right now get guaranteed medical care for 100.00 a month even if they get 85K in retirement income, own 3 houses and 5 cars and have 500K in the bank.

      “These social insurance schemes are not Ponzi schemes per se, but they do depend on population and prosperity growth and we just may not have enough coming in to keep the promises to pay out.”

      they were set up on the assumption of increasing population – not decreasing population – I agree.

      but again – keep in mind – that SS, SSD and HI are funded from FICA (and subject to the declining population problem) but Medicare Part B and C are not because they are totally voluntary – you do not have to sign up for it and you’ve not paid a penny into it.

      If you’ve not paid into it – are you “entitled” to it? Are you “entitled” to it for 100.00 a month?

      how do you answer those two questions?

      re: MedicAid is welfare.

      100% correct and supposed to be for the poor not people who own homes.

      but the point about MedicAid is this. Do you want it to be an efficient, cost-effective program that keeps costs under control or are you going to pretend it will be done away with as it goes “bankrupt”?

      what is the reasonable reality? Isn’t the reality that we will not let the poor die in the streets and on the hospital steps as they are turned away?

      if we are not going to allow that to happen and we are going to provide care, shouldn’t we do it as cost-effectively as we can and shouldn’t we start means-testing it so that those that can pay some – will ?

      this whole thing is like we are pretending we are not going to pay… but we are.. so how do you want to pay? dumb or smart?

      Now Medicaid on the other hand is welfare, pure and simple. Our tax dollars pay for Medicaid, and our tax dollars will continue to pay for Medicaid whether Virginia expands the coverage or not. To pay the taxes and turn down the benefits is dumb, dumb, dumb. Just make it clear that when the fed’s break their promise (as they will have to) Virginia will dump out of the program.

  5. re: ” Now Medicaid on the other hand is welfare, pure and simple. Our tax dollars pay for Medicaid, and our tax dollars will continue to pay for Medicaid whether Virginia expands the coverage or not. To pay the taxes and turn down the benefits is dumb, dumb, dumb. Just make it clear that when the fed’s break their promise (as they will have to) Virginia will dump out of the program.”

    if and when the Feds “break their promise” – Va has the authority to change eligibility and income requirements and in that case – Va would certainly trim eligibility back to whatever level of funding – was forthcoming. Problem solved.

    But until then – Va could use the money to put together a more cost-effective system based on Community Clinics and staffing them with para-professionals under the direction of a smaller group of MDs.

    We could have the ERs send those who do not have ER problems – directly to the clinics – which – like the one in Fredericksburg is located a few hundred feet from the ER.

    We have a real opportunity to actually improve our Va system here – reduce our own state costs such that if/when the Feds bail out – we are better off than we are right now.

    Other states are taking that opportunity and using it.

    We’re being total asses about it… partisan politics and ideology.. nothing more…

    In the context of “breaking promises” – I think it’s odd that the same folks who say we need to kill entitlements … fret over the govt “breaking it’s promises” on Social Security… and MedicAid.

    “we have to kill entitlements because if we don’t, the govt will break it’s promises”.

  6. re:

    ” Massachusetts has broad coverage but much higher health care expenditures. How is that a road map to lower costs – the carrot that Obama offered? Oregon’s Medicaid experiment proved the prediction of more primary care and less ER care wrong. Expenditures are up. How is that consistent with the Obama promises? The typical liberal answer is: Just trust us. We care and deep in our hearts we know we are right.”

    the roadmap STARTs with BIG POOLS and then bends the cost curve.

    you want perfection at the start and use that as an excuse to do nothing.

    It’s not the “typical liberal answer” – it’s the reality in every other OECD country – on the planet.

    you say we can’t do that… others say we can because 50 other countries have done it. Do I believe you? No.

    You demonize people who are trying to make changes.. rather than offering an alternative. that’s wrong guy.

    “The only offensive fiscal in a liberal world is the failure to give enough of one’s money to the government. What about results? Before McAuliffe utters a word about Medicaid expansion, he should address the Oregon situation. How can he ensure we won’t see a similar failure?”

    other states are making progress towards large pools that cover far more people. Large pools bring costs down. It has brought the costs down in other OECD countries and it has brought costs down in the govt FEHB and Medicare.

    “I’m not opposed to incremental progress. But we have strong evidence that Medicaid expansion is more costly. ”

    no you have propaganda which you are readily accepting over other evidence.

    “We have strong evidence that the Massachusetts approach is more costly.”

    you’re actually wrong… how about you show some evidence to back up your assertion?
    from a credible source please.

    “It looks to me that one more of the Obama premises for health care reform is simply wrong and that his approach will fail. But your view is that failure is better than the status quo. So what if millions lose their insurance; have to pay higher premiums; have higher deductibles; lose access to their existing doctors. Because the GOP didn’t have a substitute bill, Obama’s great failure must stand. This is a crock.”

    what’s a crock is you demonizing people who are trying to do something while refusing to offer an alternatives yourself.

    “The ACA is probably the worst piece of legislation in the history of the United States.”

    bullfeathers..

    ” It produces very little of the proffered benefits, but most the defects that we were assured won’t happen. The idea that Obama would accept modifications (not repeal) is bogus. The House passed a bill that would have grandfathered existing policies – ala “If you like what you have, you can keep it,” but Reid will not allow it to come to a vote in the Senate. There is no reform. It’s continue to harm the nation with the ACA or try to get rid of the law. You try to destroy cancer, not protect it unless the cancer is the ACA.”

    exactly how long would you be willing to wait to see if ObamaCare “works” ???

    about 30 minutes?

    you were opposed to it from the get go and offer no alternatives ..

    I do not think ObamaCare is the greatest thing since sliced bread. It’s flawed … significantly in places but so was the initial version of Social Security and Medicare and over time they got incrementally improved but it did take more than 30 minutes and nothing but strident opposition.

    you have no alternatives guy. you’re a critic who want things to fail.

    you do not want a better system.

  7. If federal Medicaid support diminished, would we see budget pressures similar to those created by federal cuts to programs funded by the Individuals with Disabilities Education Act?

    http://www.huffingtonpost.com/2013/09/10/sequester-special-education_n_3903606.html

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