Trump's war on Medicaid
Support for this podcast come from h._b._o.'s limited series are boys. The gripping true story of the tragic events that led to warn gaza in two thousand fourteen israel's shaken when three jewish teenagers murdered by hamas militants when palestinian boy goes missing tensions escalated to violence as both sides search for justice our boys follows the riveting investigation to the senseless crimes and reveals how the jewish and arab communities forever transformed based on actual events watch our boys mondays at nine pm only h._b._o. Sarah cliff is no no longer with us on the weeds. So i've been really missing the opportunity to sort of monk out about healthcare. I was really excited to sit down with jessica shoot from the center on budget and policy priorities. She's an expert on medicaid a really important weeds friendly healthcare program that there are a lot of changes happening to a in the pera really great conversation. I think you could learn a lot. Ah hello welcome to episode of the weeds on the blacks media podcast network. I'm too lazy as my guest. Today is jessica. She is a senior policy. Analyst at the center on budget and policy priorities favorite thing tank mine a lot of great stuff out there and <hes> doesn't go focuses on medicaid <hes> which is a a very important program and is going to explain it all to us. It's been big. You know the the trump administration has done a lot on medicaid waivers things things like that. That's what i want to talk about but i think it's important for people to understand like what. What are we even talking about here. So i'm going to ask like it like a really basic question a book. What is medicaid. I'm happy to answer that so just to make sure everybody knows. Medicaid is the health insurance program for low income mm people so i run establish that right off the gecko. It's different from medicare which is the program for the elderly and so- medicaid covers over seventy five million people. I don't think people realize that half of half of the population is actually kids. <hes> and another important <hes> factoid of medicaid is that it's the primary payer for long term services and supports so when your grandparents are in the nursing home they are on medicaid <hes> i'm as i was talking a little bit earlier when my grandmother was in the nursing home as she swore up and down that she wasn't on medicaid but <hes> actually medicaid covers as long term care and that's that's what's called the dual eligible population right. That's right yeah for yeah you for the elderly folks folks can be both medicare eligible also medicaid eligible but so so medicaid <hes> comes into existence in the mid six at the same time as medicare. They don't just have some more names. That's right. They share the same birthday which actually we celebrated last year. They're fifty four years old <hes> and <hes> initially it was created on really. They targeted for low income americans. I'm and as we've seen over the course of its history. There's been kind of mini coverage expansions along along the way <hes> you know kids coverage in medicaid was slightly expanded then we went to pregnant women parents and then with the affordable care act now adults else right so so the way medicare works. It's like there's a federal program. <hes> you get eligible for it by being old and it's the same where we you go right right so medicaid is not like the whole point of this waivers conversations. Medicaid is not like that so how how's it setup yeah. There's an <hes> an average around around in the medicaid <hes> walks fear is <hes> saying that <hes> if you've seen one medicaid program you've seen one medicaid program so there's two guarantees with medicaid. I'm you mentioned that it's a joint federal state partnership. I'm the i guarantee is coverage. So if you're eligible for it you get it <hes> for states <hes> they're guaranteed federal dollars so that's kind of the the to guarantee prong if you will with medicaid the fence set up a core standard word benefit package and a standard eligiblity kind of rubric that states have to follow okay <hes> but within that states have a lot of options to design <hes> there are programs that best fits the needs of their state so you can be more or less generous in terms of your benefits also more or less generous in terms of your eligibility right but there is a floor and that's the that's what you have to meet in order to get your your what we call the federal match which is a portion of medicaid spending that the fed's kicking butt on but the reason you might be i mean i guess there's more than one reason you might be more generous than the minimum but like you would get more matching federal dollars if you contributed more state dollars not necessarily i mean the way that the formula set annually in space is get between fifty and seventy six percent of the of the costs <hes> but what you would get more is if you covered more people like medicaid expansion athena. You'd see more more federal dollars if you added a new eligibility group for example okay. So what kind of variants like do we see in in in practice like what's a what's a generous state looking like in terms of coverage right like like who who is eligible in a in a sort of a big expansion stayed versus narrow one sheriff so <hes> you know in now with the affordable care act <hes> every state has the option to expand medicaid to adults. It's up to one hundred and thirty eight percent poverty in plain english that seventeen thousand dollars a year. Unfortunately you know there's fourteen states. That haven't taken that up. I'm a district resident so i'm going to say that include d._c. And my count here so if you're counting there's fifty one states so thirty seven states have expanded medicaid indicate so far so since the enactment of the affordable care act i think when you look at a more progressive state that's expanded eligibility. You have to look at the kids and pregnant women and generally they are are at a higher income level than <hes>. You know kind of like the moderate level income commodore okay so so this is like classic u._s. Welfare policy design children are maybe held blameless for the economic circumstances in which they i find themselves so the program has traditionally covered a wider scope of of children than it has of adults and then pregnant women are at a sort of. I don't know how you want to put it but you know it's it's like an interface between children and adults right. There's like understanding that if you wanna take care of kids you have to take take care of their mothers while they're pregnant. That's right so what kind of <hes> like what was the what was the history of how how did that come in well as you said when the program started in nineteen sixty five it really focused on you know kids <hes> low income families like moms but then expanded to to pregnant women in higher income pregnant women is kind of over the years how things have have progressed <hes> and you know they get the standard set of benefits. <hes> medicaid medicate is actually the gold standard. When it comes to kids coverage <hes> provide screen screenings <hes> vaccines treatment <hes> sofa kit goes in and and <hes> has a vision exam and glasses medicaid pays for both the exam and the glasses and i think it's really interesting for me. Anyways is that medicaid caid is in little corners of the world that i don't think people realize and schools is actually one of those corners <hes> but if medicaid <hes> if there's a medicaid enrolled kin in school needs a vision screening or maybe need some speech therapy or physical therapy in order to to learn medicaid pays for that oh that's interesting so so some of the sort of healthcare services that are offered in school districts are actually being covered by medicaid. I mean it's not to get into the weeds on intended. Special education is in <hes> funded as robustly as it should and so <hes> medicaid indicate help schools actually kind of spread the special education dollars more because they are paying for healthcare services as part of a child special education. Listen program okay so so with regard to children pregnant women. You're saying a more progressive state will have a higher income cutoff to try to make sure that you have fewest possible uninsured children right. I mean there's also really good evidence that shows that kids covered by medicaid when they're in during childhood are more likely to graduate high school more likely to graduate college. <hes> have better health as adults <hes> more likely to have a better paying king job pay more in taxes so there's benefits into as you were saying making sure that kids in pregnant women have the coverage. They need as one of the sort of stylized facts. It's about health insurance in the universe is that covering children is on average relatively cheap bright. Obviously there are some children with very very serious in healthcare needs but typically when we talk about giving healthcare coverage to a child we're talking about doing and you'll check up send vaccines and giving them vision tasks ask and it's stuff that it has a lot of benefits but isn't necessarily a like super cost right. It's kind of a cheap investment if you if you will you make sure kids have the vaccine so they're not getting you know measles. <hes> have the glasses that they need so they can read and <hes> and that's just gonna make them healthier <hes> adults that are able to go to college and get a good paying job and so it's kind of a cheap investment in their long-term development development but that's not what the expansion debate is about. That's about a child. I guess it doesn't matter if you have the child or not. It's just you're an adult. I mean so many benefits right like housing assistance food assistance. If you wanna help children you have to give it out family level but medical care care where you can actually pay for the kids doctor visits but not mom and dad right exactly and so. I think that's what was so amazing with. The affordable care act act is that it was actually if you wanna think about it the first kind of step towards universal coverage we were laying down the framework for covering <hes> you know every low low-income american through medicaid <hes> and unfortunately you know we still have a little ways to go with those fourteen states that need to expand to it's fourteen states and that includes texas and florida are the big strike that's right and so that's like a how do you know how much of the uninsured population in the u._s. is accounted for by the survey lack of medicaid expansion with those scissors two million people that would gain coverage <hes> if states would <hes> <hes> expand medicaid and <hes> florida and texas make up the majority of those folks routed so so that's the the the big thing there okay <hes> so then what's this the peace with the elderly and long-term care because so far we're describing. It's a program program for low income. People covers more children in some states. It's now covering for adults but like what's what's up with the old folk. Yeah i think just to kind of take a step. Ah also a should've mentioned earlier. The way i think about medicaid is it's <hes> provides coverage at every stage of life right. We talked about kids. You know when you're pregnant when you get coverage. When you're <hes> before the advent of the of the affordable care act you had to be apparent but it covered some adults right now all adults are eligible and then at the end stage of life right when you're elderly it covers the nursing home care aspect of it and there's really cool options is that states have to provide long-term care in people's homes and communities and there's lots of evidence that show that people want to stay in their homes as long as possible full and actually do better in their homes in twenty thirteen. The medicaid program hit a milestone where it's been actually more money on community needy based long term care than a nursing homes so that's a big a big stock as a lot of people with the long term care benefits are people who you might consider to be <unk> middle class raid right americans there to help <hes> folks <hes> who are maybe making a little bit more money during their working years but they have programs where if a a spouse for example needs to go into the nursing home tom the spouse that's <hes> still at home. <hes> you know isn't going to become <hes> destitute by paying all these long term care bills which very expensive okay so what is the the concept of the waiver in this landscape. I guess so far we're describing. I don't no no like america's weird. We have a lot of state federal kind of matching things but you know it makes sense like there's money. Available states have some flexibility about eligibility and benefit design. What what is it waiver yeah so going back to it. I talked to about earlier that the federal government sets kind of the floor in terms of benefits and standards and there's obviously federal law that requires certain things to be covered and people <hes> and so it a waiver is a ah allow states to kind of break the law in a way and do something different but you know one of the legal standards in approving a waiver is that it has to further the objectives of the medicaid program and the central tenant of medicaid is to cover low income people and provide coverage so so what kind of minimums are we. Are we talking about like what's the what's the issue here so in terms of <hes> eligibility. What we're seeing now is that the trump administration nation is using waivers to take coverage away from people so we've been seeing work requirements for example and <hes> you know there's been some odd <unk> opt optimistic news <hes> in the sense that <hes> recently <hes> the courts have vacated these work requirement waivers in arkansas kentucky accuracy and new hampshire but it unfortunately it was a little too late for about eighteen thousand people in arkansas because they lost coverage of you but so what's so it sounds like you're not in favor of but like glitz can can you paint a picture of like what's a what's a reasonable waiver requests like out. How does it further the goals of the medicaid program to say you can go below the minimum benefit level well. I think that's the million dollar question that's being decided decided in in argued in court <hes> you know my perspective. Is that a good waiver. A waiver that furthers the objectives is actually expanding coverage <hes> i'm an good example of this is historically before the ford <unk> <hes> states would use these waivers to expand coverage to low income mm-hmm adults <hes> that are now being served by the medicaid expansion so states lake arizona new york massachusetts <hes> wisconsin all use these waivers to expand to <hes> you know adults to low income adults that don't have kids. What would you need to get wave to be able to to do that. <hes> it's actually kind of a very wonky thing. It's <hes> there's two components of waivers. One is that you're waving federal law essentially allowing on states to not comply with certain provisions of medicaid law and the second component is authorizing <hes> healthcare costs that wouldn't otherwise is be medicaid reimbursable so because before the portable care act low income adults weren't generally eligible for medicaid <hes> you needed special authority authority authority for a state to say like hey can. I have some federal dollars for covering the folks and i mean i guess if you like the <hes> the the leftists takeover the state legislature somewhere and say we wanna take another run at a single payer healthcare system like they're gonna want to try to get get some of the i mean they're going to have to raise taxes and like do a whole ringing but they're gonna want to try to get some federal money right and so they're going to have to to try to write some kind of waiver. <hes> you know there's lots of smart people thinking about that. <hes> i guess depending on how they wanna set it up. You know medicaid. The que could be a factor in that in that proposal the the money the basically though it's like so there's federal money that states are getting thing. You wanna do something with healthcare like you're. You're gonna wanna try to get more money sure and the other thing that going back to your initial question russian about like what's a good waiver <hes>. There's really cool things that states are doing to improve health and lower cost through delivery system reform efforts send their states like new york in california that are trying to do different payment arrangements to incentivize providers to provide better care lower costs and so you know that's kind of in my mind. What a what a good waiver. Okay so what what what does that mean that's like a standard heard. Setup is like there's a list of procedures and they all have some payment level that you get for it and it doesn't matter by you know if it works or whatever else well in in terms of <hes> kind of more traditional medicare yes states have flexibility to set set their payment rates at whatever level that they <hes> decide but i think the key thing to remember with that is that they have to be <hes> at a high enough. I level to ensure access and i think <hes> you know what's really disturbing. I'm recently is that the trump administration actually <hes> rescinded at a rule <hes> that was finalized in twenty fifteen that would make sure on these provider rates are set high enough to ensure access for folks. Okay here write to read. This is talking about so you have private. Insurance usually pays so much for things medicare usually pays a lower rate than uh-huh than that and takes advantage of the fact that it's really big and then medicaid varies from state to state but but the rates are lower lower than medicare rates and a lot of doctors but relatively few providers can afford to turn away medicare clients <hes> even though taking a discount but like the medicaid rates get so stingy that some providers will turn them that i think one point i just would like to argue with with is that seventy percent of doctors actually do accept medicaid patients so this idea that <hes> you know medicaid patients aren't aren't you know don't have access to doctors is unfounded <hes> but yes you're right. <hes> medicaid does set their payment rates. <hes> you know a little bit lower aware than than medicare and indefinitely commercial coverage but you were saying the state could or maybe there was a twenty fifteen rule to okay okay. You have to set it high enough. I don't know how that worked but i assume it's like some percentage of providers are going to take it or yeah we sent actually sent sent at <hes> kind of like the access to services that we that you know states had to make sure that their rates you know and that access for those particular services services were sufficient that people you know know you know had access to these providers so now one stingy option would be to keep all the eligibility ability worlds the same but just keep putting the rates down lower and lower and sort of who cares well lower and lower to the extent that <hes> you know. I would hope c._s. Harass would you look at these and say hey. The seems weird and <hes> you know. It doesn't seem like these rates are higher enough to ensure that people can actually find a doctor to go see okay. Let let's take a break and then we come back. I want to dive into medicaid waivers and requirements. It's been a long day at work. 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Daniel subscribed to digest for free today on apple podcasts or in your favorite podcast. Let's talk about work because this has been the the hot topic i think <hes> so which which states would have done this said there are six states that that have a waivers <hes> approvals that i mentioned arkansas new hampshire and kentucky. There's are kind of set on the side. <hes> arizona has a work requirement waiver as does utah <hes> wisconsin and indiana okay and so what is the the the idea of this is that it will get people to work that <hes> apparently is the idea <hes> but there's actually evidence <hes> recently that from <hes> some harvard researchers <hes> that took a look at the <hes> situation in arkansas and said actually we don't see any <hes> impact on unemployment but what we are seeing as a as a higher rate of uninsured folks in arkansas and that makes sense since eighteen thousand people lost is coverage right so so they lost coverage because they sue we're talking about people who are not working had been enrolled in medicaid and now they lost coverage coverage and they were not suddenly inspired to go to go get jobs well. I think i kind of an impact that in a couple of ways the first one is that the majority of medicaid beneficiaries are in fact working so the the reason for eighteen thousand people losing coverage has to i'd be more than than just you know. People not working choosing not to work grade. There's going to be in that number. There's people that are working <hes> <unk> but didn't meet the threshold so in arkansas people have to work eighty hours a month to maintain their coverage so think about someone that may have seasonal employment employment right <hes> or just might be working at a store or restaurant in their hours fluctuate and they just in that given month just didn't make the eighty eighty hour threshold so they're in that eighteen thousand group. They're working just not eighty hours for that month. The second bucket of people are people that should be the exempt from work requirement so think about folks that have a chronic condition and that makes work just not possible <hes> or disability or might be suffering offering from substance use disorder. They have to get an exemption but you know there's lots of red tape. <hes> i was actually reading a really interesting article up <hes> in the concord monitor in new hampshire where the woman was trying to get <hes> an exemption from her primary care doctor and they said sorry you you need to go to the to your nurses to get it in the neurosurgeon said no you have to go to your primary care doctor so there's lots of red tape and people are getting caught up <hes> <hes> in that the people that should get exempt from the work requirement so i mean if you're like i don't know if you're an addiction recovery and you're having trouble getting job and you need medical medical treatment and trying to get better for all those same reasons you might also struggle to like get it together exactly all your forms does exactly and and it also extends the third bucket of folks that i want to talk about is people that are working but we're just really confused used about what happens with how to report their hours. <hes> there's a <hes> a perfect example of this <hes> a gentleman <hes> in arkansas mr mr macgonagall had a job but also had c._o._p._d. Which is a respiratory disease a needed venison in order to function and go to work. He works eighty hours. A month reported it one month and thought he was good to go didn't need to do anymore. Reporting you know in any subsequent month but in fact you have to report report each month. He just didn't realize that okay so that's actually fascinating so it's so it's like a month to month thing where like each month you come and say hey. I'm still work rights and in his case i mean it's fascinating but heartbreaking at the same time because he went to the pharmacy to pick up his medicine then pharmacists said hey sorry your medicare coverage is no longer effective and do you want your medicine but of course it's it's really expensive so he said no <hes> and ended up missing a lot of work and lost his job so it's the exact opposite of this the premise that somehow working well <hes> you know help you get covered. You know what i mean. I think it's important for people to understand that you know when you think about policies right you can you describe them in the abstract but they're not self executing right so like <hes> you know the other week i got an angry phone call from my bank because there had been like an auto debit of my electrical bill and my balance gone below zero oh and like a bit like i wasn't actually out of money but i had just like messed up. I had forgotten which account this thing was from. I'd forgotten where i paid a credit card bill off from and the money was in the wrong thing right and so you know it's bad. I got a you know my my bank yelled at me. I think they charged me five dollars but it's not the the end of the world right. I didn't lose health care for a month because i had this up. Well what's worse in in mr mcgonigal's case is he didn't lose healthcare for just the month he lasted for the rest of the year so <hes> he couldn't get you know back onto coverage coverage until january <hes> you know and then he lost coverage at some point during the fall so it was more than just a month of coverage loss and where does this this come from like what was the the the the idea like what what what what are state governments that are doing this trying to respond onto <hes> quite frankly. I'm not sure <hes> you know. I think it's just the political ideological idea that <hes> of personal responsibility but as i said you know work requirements aren't showing that there's been an increase in employment in you know in arkansas <hes> where they have actually been implemented so i mean this goes back to sort of old disputes in in american welfare policy. Why did it suddenly we've talked about on another another episode of the weeds as there used to be a families with dependent children program. There was a lot of controversy there was a big welfare reform and you know i think the the thinking of the clinton administration there at least was that there was a special politics of cash benefits right and cash benefits to non working people. We're going to be politically vulnerable ball but that in kind assistance you know might be more sort sustainable right the idea being that nobody is like going to the doctors and fun ride so it's getting you could take money and like go i. I don't know what like you know by some beer right. Have a party but you go to the doctor when you're sick. Primarily read zooey can't be there's no the universe in which your livelihood is like getting medicaid right and i think that's part of the reason that during the late nineties during who knows <hes> economic reform period medicaid was actually kind of divorced from <hes> the other you know assistance programs <hes> <hes> that helps low income families and so you know i always view medicaid as its health insurance and we should treat it as such <hes> and you you know imposing work requirements <hes> it was unprecedented. <hes> you know actually during the last year of the obama administration <hes> carr's the federal agency that oversees medicaid <hes> denied work requirements in arizona and new hampshire saying going back to the to the beginning that work requirements don't further the objectives of the medicaid program which is the standard under which you know the feds have to review medicaid waiver proposals muscles but so then this is even if it doesn't generate extra employment it does save money right. I mean if if if if eighteen thousand people in arkansas wind up losing medicaid benefits <hes> whether that's because they're not working because paperwork problems because of whatever ride like that's a that's a savings on the state budget yes but that's eighteen thousand people that no longer have coverage and so when you talk to maybe hospitals and doctors. They're now having to treat people that no longer have insurance so they're uncompensated. Care costs are going to rise so it's just going somewhere else. The system meaning that the hospitals and doctors are going to have to eat it because no one has coverage anymore and just to just to be clear on this because we were starting my talking. What about the sort of benny universes of medicaid. This is four adults set the set the stage here this is for the expansion adults also those adults without kids <hes> that make up to seventeen thousand dollars a year and so and that helps explain like what is this list of states right these he is our <hes> kentucky arkansas in particular right are very politically conservative states that unlike many of the other conservative states actually did the medicaid expansion right because i think sometimes you know you can hear oh. There's this <hes> kentucky work requirement thing and that's like <hes> these kentucky politicians must be unusually evil or something but it it is actually a rise out of the fact that kentucky did the expansion whereas like mississippi in alabama haven't like they they don't even have a population that could take benefits away from the that's right they just simply haven't expanded their one of the fourteen that of of yet yet to take up this option kentucky arkansas had democratic governors ride monday i expanded so this has been like a way we to do a partial walk back of that expansion yeah in particular in kentucky's case <hes> because kentucky he was really the gold standard you know in terms of having a great <hes> system that they you know are able to use one affordable real charac took effect in january of two thousand fourteen and they did everything right and now you know you're seeing kind of as you said a rollback of not just work requirements but the other kind of restrictive policy that the trump administration is really moving forward on is hiking up premiums <hes> for low income people people and so you see that in kentucky <hes> you see it in arkansas and some of these other red states. How does that work so okay. This is a government program is gonna give you health insurance. If you're poor right. Why would have a premium well it generally for most people that it doesn't this is why you need the the waiver right eight to do something different to break a kind of federal law in that in that respect <hes> and so you know to be fair. The obama administration did allow states to impose minimal premiums on on the expansion <hes> population but what we're seeing is that the trump administration is not only charged letting <hes> states dates charge more <hes> but they're also charging <hes> even poor people these premiums so the with the obama administration this was part the sort of political negotiations over expansion of remembering correctly like at first they had thought okay. This is such a generous deal. All the states are going to do it and also there was this clawback provision was supposed to really really make them do it right but then the <hes> the supreme court it's like throughout the clawback thing and then the political resistance was bigger than they had anticipated right yeah so so they came up so they reached compromises in some places where they said okay like we will let you do some of these changes premiums and stuff. I like that that's right but it was always you know the guiding star <hes> in dioramas was trying to get as many people as possible and so so in that in that context the compromise was okay. We'll allow you to test these new kinds of models. <hes> so long as you know. Coverage is expanded shannon's. The push poll was like obama wanted states to do medicaid expansion writes. A lot of republicans didn't wanna do medicaid expansion so he was right. I mean indiana <hes> then governor pence expanded medicaid and but also kind of made a deal with the obama administration nation to do something different didn't have work requirements though at that point but so <hes> but the the head of c._m._s. is so mike pence brought over from india right right so what what's happening exactly what the premiums though <hes> as i said they're just letting states charge <hes> higher higher amounts <hes> and kind of like going down to reach <hes> folks further down the the poverty line and what happens when you do that i mean to some pe- the ball i guess they spend more money. The state saves org. I guess collect set extra revenue but i mean people just not sign up yeah. That's exactly there's a robust body of research that shows that premiums deter people from getting care and so what you're seeing is people just not enrolling enrolling into the program or not going to the doctor <hes> so it. It's really not an effective tool for us right <hes> but but i mean i guess again just like on the flipping back on the politics. I mean this is. This is the same tug of war right. I mean you have an administration that has not invested in medicaid. Get expansion happening and you have that same imperative to like not expel them from the non expansion states into to pair it back elsewhere. Yeah i mean i would say a step further. The trump administration not only doesn't support expansion but they're really trying to take coverage away from people which is what we're seeing what the worker requirements right and so you know you said that what are this kind of prospects for stopping that sin in court i mean i like the whole idea of like you could just wave. I don't know like the great society programs. Adv existence is a little like a little new to me <hes> when when the started coming up a couple years years ago yeah i i will say that not everything in the medicaid program is up for grabs right so just to set your mind at ease but everything is on the table to to be waived <hes> in terms of the litigation with the work requirements as i mentioned you know the courts vacated the waivers in arkansas kentucky new hampshire. That's like a district court ray and so the next round is coming up in october for oral arguments <hes> so we'll we'll. We'll see what happens in october eleventh. Is the day actually okay so this is gonna it. We got to see what john roberts thinks. I i would imagine that it would go up that far right. We're right and so you know something that you you read on the internet if you if you google around there's a conservative view that all this medicaid stuff is like nonsense and medicaid doesn't look actually doesn't help people yeah the claims is that those folks are using <hes>. It's just false and there is a robust body of evidence showing <hes> the opposite. I think you know <hes> while personally it was very upset to see that the supreme court made medicaid expansion effectively optional it it did <hes> kind of create this natural experiment right so we're seeing all these studies are showing what <hes> the changes in states that expanded ed relative to those that didn't and we're seeing that medicaid expansion is saving lives <hes>. There's a recent report out that said if the fourteen eighteen states had expanded over fifteen thousand lives would be saved. I i yeah that's a pretty compelling <hes> statistic right yeah i mean because this is so so with a skeptics come from this old <hes> thing that happened in oregon right where they i forget exactly why it happened where it was like dame ran out of money he or something and so they they had to randomize who was going to get medicaid it wasn't they ran out of money so they used a a medicaid waiver. Um i'm and you know again going into the weeds of waivers there is this thing called budget neutrality which means that states can't the federal government can't can't spend more than it would absent the waiver and so what oregon was trying to do was provide additional benefits to folks but they had to stay within this budget neutrality <hes> limits and so they you know created a prioritized list of benefits <hes> and so and you know that's the study that you're referring to but so they they wound up doing lottery behind every lottery there's a good research opportunity right right <hes> and this one showed that there was not a a change in in health outcomes that may be so but the body of evidence that that we've been seeing or the last couple of years with medicaid expansion points otherwise we're seeing improvements in health outcomes <hes> in a reduced racial <unk> disparities particularly in cancer treatment. <hes> you know one of the interesting facts that i find about medicaid expansion is that it's actually improving people's is credit scores and that's because <hes> having coverage reduces medical debt and medical bankruptcy so improve credit scores is actually helping when these low income people afford mortgages and car payments so again going back to medicaid is an little corners of the world that you didn't now about <hes> who knew medicare mortgages were together. I mean i do think that's important because even in this oregon study that i've heard from conservative servers i mean it does show that improve the financial wellbeing families that got it and if you think about insurance in general i mean insurance is a financial product right obviously obviously with health insurance like ultimately the goal is to get useful medical care but the but the financial value is not like a trivial thing that you would wave wave off. I mean i think all the time. I have a four year old son and you know all four year olds. He has been to the doctor like a bunch of times and i bet if you went through through some like science counterfactual you would see that it has actually not had a meaningful impact 'cause 'cause like you know god bless like he's had good fortune and like hasn't had any medical problems and he's gone through all these checkups and they keep saying oh you're fine but it's not like my fallback into having like if i'd had a less generous insurance positive we'd had higher copayments are higher deductibles. I wouldn't have just been like that no pediatrician for you. I like i would've spent more more money right or if i was too poor to afford it. Then i might not have gone in. I would have been incredibly stressed out right all the time right and so it's like being able to go to a doctor when it seems appropriate and not have thad bankrupt. You is a really useful thing over and above the value of treatments that people see right and to your point about having having means to pay. Maybe a higher co payment. <hes> you know there's lots of research that shows that copays in medicaid deter people from going to the doctor right so it's kind of that push and pull. Do i pay my rent or do i pay for my kids. You know prescription right. I mean this has been like a big. I i feel like it's kind of like back and forth in the thinking on this sound like where people over consuming healthcare or you know should ability to thanks to expansion. We now get to compare right health outcomes in arkansas verses texas texas. Yes those are bordering during staples louisiana versus alabama right and so and so what what what are what are we. What are we see on that that you would really point people to it. Yeah you brought up louisiana louisiana. They have this really great dashboard and each month they update and show how many people got cancer screenings and how many <hes> averted averted deaths that you know they projected because of these <hes> cancer treatment of screenings how many people now have access to you know blood pressure medicine to lower their their <unk> their hypertension so it's we're seeing that coverage matters and coverage is actually helping people <hes> and improving their health uh-huh so that's been sort of <hes>. I mean there's again a big. It's a political issue in louisiana because again. This conservative state has a democratic governor. He's like trying to run for reelection wants to sort of do it but also what what does it do to state finances. I assume like always with you know oh programs right. It's like it sounds nice but this costs a lot of money to yeah. We'll as we started off the show here we talked about how it's a joint federal and state program so the feds kick in a portion of the medicaid funding for medicaid <hes> an expansion is a really great deal for states dates because the feds kick in ninety percent much higher than like the regular rate in which they they chip in <hes> so states are just on the hook ten percent percent of of cross which is not to say that it's not you know a meaningful amount of money for states but i think what's really interesting is that we've seen expansion. Help state budgets and <hes> one example is that <hes> states are able to offset costs from steep programs that you know were treated behavioral mental health <hes> issues or the criminal justice system for example so we're in schools as i was talking about earlier so we're seeing that medicaid medicaid and medicaid expansion are really helped is helping state budgets in kind of moving the money around. Hey i'm i'm jason delray and i'm hosting a new podcast called land of the giants in it. We examined the most powerful tech companies of our time. Season one's called the rise of amazon. How about how jeff bezos turn what was just an online bookseller into one of the biggest companies in the world and how transform the way we shop live and work. We'll explore how amazon prime is the key to the company's success and how it's something you'll never quit. We'll see what happens when amazon builds a warehouse in a small al- kansas town and then also what happens when it decides to leave and we'll ask why is amazon building microwaves powered by alexa and what is with all the robots it's built and of course we'll tackle. The biggest question of our time is amazon tubek too powerful land of the giants from recode and the vox media podcast network new episodes come out every tuesday. Listen and subscribe for free on apple podcasts or in your favorite podcasts at abbey was an investigative reporter each week pulitzer prize is winning journalist charles duhig takes listeners toughest problems in the new slate podcast how to like how to tell the perfect joke or how to fire a bad employee even how to rob a bank charles finds answers to the questions we've always wanted to ask but couldn't until national so check it out subscribe to how to an apple podcast or wherever you listen and learn more at slate dot com slash podcasts slash how hyphen to another aspect of this has been controversial right is is some states i man and utah idaho there were states they had done expanded on ballot initiatives and then the governors aren't doing eh yeah <hes> it's kind of breaking to see where the the will of the voters is being overturned <hes> by state legislatures. I think you know the great for example. You just mentioned utah. <hes> the initiative passed in november the lawmakers say policymakers got together during the wintertime and completely -pletely changed <hes> enrolled back with the voters wanted and so now we're seeing utah only cover <hes> a portion of the medicaid expansion population which is covering fifty thousand people fewer people <hes> and costing the state more money because they're not able to get that <hes> ninety percent <hes> federal what happened there. I mean like literally they just like got together and passed a law that overrode the the the initiative. Yes doesn't sound very nice okay fair enough so i and and something similar had happened in in maine but now they have a new governor right so it's all sort of mood one <hes> governor mills started expansion and they're. They're moving forward okay so but before i let you go you know i i like to ask people. Come in <hes> what what what. What should i ask you. What what did we miss here well. I think the one thing that we didn't talk about although it's been a topic on your show is <hes> the lawsuit <hes> that's going on in texas that would completely overturn the the affordable care act. That is an excellent point. We didn't mention that so if if if i can just talk about what would happen to the medicaid <hes> that would be great yeah yeah yeah. No actually i wish to remind people in case you haven't you haven't seen <hes> earlier discussions of of our friend mitch's lawsuit. The theory theory here is that to forcible care act contains the individual mandate which longtime american politics fans will remember and that the supreme court ruled that the mandate was a constitutionally permissible exercise of taxing power but then in the twenty <hes> seventeen seventeen corporate tax cut bill. They eliminated the penalty that the way they did it to qualify for budget reconciliation rules was they set the penalty see to nothing so the theory is with the penalty at nothing. It is no longer a tax but it still on the books so it is now oh an unconstitutional non-tax and also it isn't several ball from the rest of the law so provisions that are completely unrelated. Go no way and that's what we're getting medicaid right and i think to your wonderful explanation of arguments here. I think many opponents of the affordable oh character even they even agree that this is crazy and the administration took the unheard of step in not defending the affordable care act a federal law and and instead is arguing that it should be overturned. <hes> and i think you know there's kind of two two buckets that i kind of want to just talk about one. One is just the impact. That's going to have people right. I'm not kind of a private insurance marketplace person but i will just fly that twenty million people are gonna lose coverage that includes people medicaid expansion and those that are buying <hes> coverage on <hes> the obamacare market voices. What's the balance balance of that yeah so thirteen million <hes> our medicaid expansion okay so when you hear this lawsuit is going to cost twenty million people with insurance. That's primarily early medical <unk> primarily medicaid <hes> in it's also going to allow insurers to go back to denying care <hes> or charging people more money if they have a pre existing condition <hes> but i think the other two components i wanna flag <unk> relates to medicaid people <hes> is that it could roll back ah coverage for kids and so one point five million kids could potentially lose their medicaid coverage how well the affordable care act actually expanded eligibility for kids as part of that core eligibility requirement that states have <hes> and you know some of these kids might be able to be covered in other insurance programs like <hes> chip which is the children's health insurance program <hes> that kind of sits on top of medicaid shoulders older if you will but under chip they have a narrow benefit package and it's <hes> has higher cost sharing so it's not as good of an option for these children <music> as medicaid and the second group i wanna flag are elderly and people with disabilities so the affordable care act <hes> had a lot of different a friend <hes> programs in options for states to move towards more community based long term care. We talked about that earlier and all of those options options would would go away <hes> and so that would mean seniors and people with disabilities would have would be may be forced to go back to the nursing homes for karen staying in their homes and the second kind of other bucket if you will of of impact that this lawsuit would have on medicaid is that it would just create an unbelievable mess yes so the affordable care act modernized and streamlined how states do eligibility villa conduct eligibility determinations medicaid <hes> the feds the states at spent millions of dollars updating <hes> i._t. He systems to to accomplish the streamlining effort <hes> and if the affordable care act is overturned <hes> states will have to go back to a very old and complicated way of determining medicaid eligibility. I'm not even sure if they can you know <hes> resuscitate these world i._t. Systems so i'm not sure how states are going to administer the program. The twenty million people definitely losing coverage chaos throughout the rest of the system right anarchy disaster cassie all right okay. What would that reassuring thought. Thank you very much has scheuble center on budget and policy priorities <hes> thanks as always to our sponsors and to our producer jeffrey geld and the weeds will be back on tuesday <music> hi medical clue editor in chief of eater and i'm daniel janina producer here at meter and we are here to tell you about our brand new podcast digest every week on the show we dive into the weirdest funniest and most important stories in the world of food with the inside scoop from the biggest names in the industry expert insights from the newsroom. It's a really fun time time so i would say subscribe to digest for free today on apple podcasts or in your favorite podcast app. Hey it's peter kafka. I i host a podcast called recode media. 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