Monday, January 6, 2014

America Should Learn From Medicaid

Today in the Washington Post, Ezra Klein analyzes the biggest success of the Affordable Care Act – Medicaid – and how we are unfortunately not hearing much about this programs success.  Klein goes into an analysis of why he believes that Democrats have not been trumpeting the expansion of Medicaid as much as they should. He claims (and I agree) that Democrats are hesitant to sign Medicaid’s praises because of America’s hesitancy towards expanding the social safety net. Because “Obamacare” was sold as a program by which individuals who were not able to purchase private health insurance (whether that be for pre-existing conditions, the unaffordability of an individual plan, etc.) can now do so, one wouldn't want to use as a support for the Affordable Care Act the expansion of a government single-payer system. Further, because about half of the State have refused to expand Medicaid, the success of the program is limited to certain States (mostly Democratic ones).

This reluctance of Democrats and the Obama Administration to emphasize the success of Medicaid is unfortunate, as something like that program is actually where we should be headed as a country. Studies have shown that Medicaid costs have not increased a substantial amount compared to private insurance and Medicare and further studies have also shown that Medicaid is more cost-effective on a per capita basis than private insurance. This makes complete sense, because Medicaid, as a government program, has greater buying power with healthcare providers than private insurance companies do. This difference in buying power between government and private insurance companies is why almost every other developed country that has a form of single-payer spends less than the United States. Medicaid also has access to False Claims Act qui tam suits for fraud, which private insurance companies do not have access to outside of California and Illinois. These are just two of the reasons why Medicaid is more cost effective than private insurance. 

Granted, many conservatives claim that there are fundamental problems with Medicaid. For example, because the government is able to bargain for lower payments, and because those payments are significantly lower than the payments that doctors receive from private insurance plans, doctors are hesitant to accept Medicaid patients. Because of this lack of access to a primary care physician, that increases the usage by people on Medicaid of Emergency Rooms, as the recently released Oregon study showed. But these critiques are deceiving, because in reality the critique only works if you look at Medicaid as the outsider in the “private insurance” market.  I could use the same data, look at it from a different angle ,and say that it is not Medicaid that has the problem. Instead, I could just as legitimately claim that it is the private insurance market which is the problem. It is because the private insurance plans pay more than Medicaid that doctors will not see Medicaid patients. It is because of private insurance plans that Medicaid patients who cannot find a primary care physician use Emergency Rooms more.

Democrats need to up the ante. We need to emphasize to America that compared to the rest of the world we DO have a substandard healthcare system. Does it look great on the outside? Yes. We have gleaming new operating rooms, state of the art equipment, and doctors paid out the wazoo. But does that mean that we, as a society, get better care? No. In fact, other countries spend substantially LESS on healthcare, and have better outcomes. Democrats need to shout this from the rooftops; and we need to move to a form of single-payer.  

Gay Marriage Stopped in Utah - I'm Not Surprised.

The Supreme Court, in a unanimous decision, issued a stay of Judge Shelby’s opinion striking down Utah’s Amendment 3 (gay marriage ban). As much as members of the LGBT community are upset about this development, I’m not at all surprised. I was actually more surprised that the 10th Circuit didn't stay the decision itself.

Judge Shelby’s opinion, though good, enunciated a lot of ideas that have either been rejected by many Courts (same-sex marriage bans are discrimination on the basis of sex – which he really didn’t get too because he found the ban failed rational basis review) or are pretty weak to begin with (that same-sex couples have a “fundamental right to marry” – I don’t think that we do based upon Due Process jurisprudence). The opinions strong points – the nature of “responsible procreation” etc. – haven’t really had an opportunity to be analyzed by Circuit Courts and in many cases such reasoning by the State has been upheld by Courts around the United States. Granted, most of these unfavorable opinions were issued prior to the landmark Supreme Court case of Windsor v. United States, but I don’t personally see Windsor as a useful case to argue against state same-sex marriage bans (given its very limited focus and federalism issues).  Therefore, because the issues in Judge Shelby’s opinion were rather revolutionary in the Court system, it SHOULD HAVE been stayed by the 10th Circuit. Granted, the State of Utah botched the stay request, and its briefs to the 10th Circuit were laughable, but that doesn't hide the fact that the Court should have granted said stay.

Regardless, I want to take this opportunity to remind my readers that the Supreme Court had an opportunity to deal with marriage equality on a nationwide scale last year in the Prop 8 case. But they punted, instead deciding to issue an opinion based on standing issues. Read into that what you will (I have, and I read that Kennedy isn't ready to legalize marriage nationwide), but that fact must be remembered. 

So now what we have is a case being appealed in the 10th Circuit (UT), one being appealed in the 9th Circuit (NV), and many going to trial this month and next around the country. 2014 will be a fun year!
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