By Matthew Holt
A long time ago in a different country, there was a landslide choice of a population that sought changes. And the change they obtained. The Americans had been campaigning for national medical care since 1917. There were leg failures in 1933 and 1946 and 1961. But in 1965 they obtained it. Order or.
But something strange happened in Congress. Out of the political dish making a plan that “cared for” those over 65. While another plan came out that “help” built the poor. (He stole that of the wonderful Adimika Arthur). Even more strange, the Medicare program was and is a program funded by the federal government. The Medicaid program was a state addicted program, just although it was at least half financed by the Federals.
That meean that Medicaid was always vulnerable to the whims of states. Or for the course, many states had already demonstrated dimitations in how they treated their poorest and minority populations in the past (think of slavery, Jim Crow, KKK, separate schools, beverage sources, buses … The idea is understood).
Then, while Medicare became the Salvador program for anyone who reached 65 years, and then for those who were disabled or kidney diseases, Medicaid was a program for poor people who later received a bad treatment. (He stole that from Jonathan Cohn). And at this time in 2025 it is under a severe threat once more.
Before getting to that threat, Derth is looking at the program. Medicaid has evolved and now covers most of the homes of nursing homes (for “poor” older people), take care of the disabled and only pay the premiums of Medicare part B of Medicare for people too much for to pay their own. It also covers health insurance for poor people under 65 and in those states that accepted the expansion of ACA Medicaid, that is a considerable number. Of course, these are people under an image that makes them buy in the exchange established by the ACA. And Usuary Medicaid includes the Chip program, an insurance program that covers poor children established with Clinton in 1997.
This table of the venerable KFF shows that although 75% of people in Medicaid are poor, children under 65, and not classified as disabled, 50% of the money goes to those who are not.
All this results in a bizarre world in which there is a federal government program for people over 65 years and disabled, and then a completely different statute, which spends 1/2 of their money on people who are over 65 years old and who are and whoo are are also In the Federal Program. This is simply stupid and has always been.
Or of course, there is more than that.
Many states that do not share that confederate heritage have done a lot with Medicaid. Oregon, for example, has always tried to increase coverage and spend money on community care in a different way. The doctor and three times the governor of Oregon John Kitzhaber is very vocal about what they did before ACA and how Medicaid must change to reflect these new realities.
Since 2012, under an exemption from 1115, Oregon Medicaid has been provided through new coordinated care organizations (CCO), community -based organizations responsible for providing quality medical care, while focusing on community health. They operate with a global budget indexed to a member per year per year a growth rate that is lower than medical inflation. The CCO also request the registration and benefits of Mintain, while complying with the rigorous metrics on the quality, results and patient satisfaction. During the first exemption period of 5 years, Oregon and qualified with increasing and operated people. All CCO with the quality and metric of results required, and realized a net cumulative savings of $ 1.1 billion.
In fact, Oregon, in no way the only state that has done something is different. California massively expanded coverage after ACA and now 15 million people or over ⅓ or its population is in Medicaid. Together with that, there has been a ton of experimentation within the program. Those 1115 Waatvers, which must spend that federal money in a way that is not sent in the law of 1965, have worked overtime in the gold state at the state level and county. The survey is that Medicaid here has changed to one leg to a more complete program called Calaim (California Advance and Innovation Medi-Cal) that covers all kinds of things that are not in traditional medicine, including the caras, community health workers!) And fever.
Despite these improvements, he suggests that Oregon or California move deliberately and become poor. (He stole that line of my late boss in Harris, Bob Lietman)
But there is much more than happening in Medicaid nationwide. Since the 1990s, most care has been directed to private health plans, although many are publicly administered. But Centene and Molina have especially created very profitable businesses in Medicaid in a similar way to how United, Human et al, have extracted Medicare’s advantage.
And there not strictly speaking operating through Medicaid itself, we have also built many other sources of financing for security networks suppliers. These include the 340b program that hospitals use to earn money with drugs, payments of dishes that go to hospitals that treat more of the poor, and there are approximately $ 35 billion+ in federal funds for FQHC, which is a lot of a lot, many of the days treated much, many of the treaties. Loted and Treat Menyided and treated and treated and treated and treated. Treaty. Treaty.
So we have built this incredible swollen disaster of a program. It is mainly administered by organizations that are commercial or county plans that do not resemble the plans of the Americans regular employees from those who obtain their insurance. These plans buy attention to a network of facilities (FQHCS, County Hospitals et al) that obtain a large part of their Medicaid money, or use many other ways of raising funds. And these suppliers institutes do not seem or share a lot of clientele with regular doctors and health systems where most Americans employed or those who are in Medicare receive their attention.
And you thought separate but the same was abolished in the 1950s!
Now, of course, Medicaid is under a great threat, since it is somehow here. The Trump administration, with a South African immigrant wandering with a literal and figurative chainsaw, has promised cuts. The most common number is $ 880 billion in 10 years. Now that it is a large part. $ 90B – The annual equivalent – is about 15% of federal expenditure on the program. If the course this is a program that spends a lot in the red states, but, of course, much of that expense in red states is in black and brown people, and many supporters of Trump Blancos do not realize that it also covers many of its white political allies. Wendell Potter and Joey Rettino pointed out that, since many states call something different from Medicaid, it is possible that a lot of Trump voting voters in the red states may not realize that it covers the issue!
Even so, a 15%reduction, in a program that is thin as peanut butter and already pays low rates to suppliers and elderly homes, will be a problem.
The other question is around regulation. Those omnipresent 1115 WAAAT allow many programs that are not in the original regulations and, of course, obtaining or renewing an exemption from the new HHS and CMS can be complicated. Surely Republicans are obsessed with ensuring that someone in Medicaid is working. These “work requirements” were implemented in some states during the last Trump administration. They ended not saving money, and they were unnecessarily honorable. But given the wishes of the current administration that are as criticized as possible, it is very likely that ideology wins here and the work requirements or other silly shit can impose in each state.
Therefore, the current fight will be the Democrats in the blue states trying to maintain Medicaid as they are. Well, see how that develops, and if trumpets can maintain their thin majority when some of them realize what it means.
But that is not what we should do with Medicaid. Instead, we should take the lunch that Clinton tried to take, but that Obama and the ACA were granted.
We should reform or defuse Medicaid. We should abolish it.
Instead, we must use that money from Medicaid to create an adequate universal medical care system and put people in Medicaid on the same financial and delivery platform that I will Medicar and Commercial Insurance. Whether we do it in a world of multiple payers as the Japanese and the Germans do, a mostly individual version such as French or Taiwanese, or in a nationalized system such as the United Kingdom and Sweden, would be to eliminate the second medal of health medal of health of health of health of health health of health health of health health of health health of health of health of health of health of health health Health Health Health Health Health Health Health Health Health Health Health Health Health Health Health Health Health Health. They when they are young and idealists, and do not have to worry about how much each patient pays, since they would get the same amount, no slightest was touring.
Let us make the political impulse defend equal treatment for all in the United States, and we do not maintain a well -being program that arose from a political error in 1965.
Matthew Holt is the thcb editor
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