One of the most important questions to ask about any government program is: What’s the point? That might sound easy enough to answer in most cases, but the specifics of a law can make all the difference.
It matters not only for how the law is implemented. It tells us a lot about the priorities of the lawmakers who wrote, debated and approved it. Let’s take a closer look at how this is playing out for a very timely issue.
One of the most potentially transformative bills passed in this year’s legislative session is the one allowing Gov. Brian Kemp to seek more flexibility in how our state administers Medicaid and the Affordable Care Act.
Several factors will shape what kind of flexibility he pursues: his priorities and beliefs, the unique needs and resources here in Georgia, and of course what the Trump administration will allow. Taken together, those factors help answer that question about the point of the programs.
As with seemingly everything these days, however, there’s an additional factor: the courts.
While waivers are not new, especially for Medicaid, some of the ideas driving recent applications are relatively novel. One of the most controversial is to impose work requirements on Medicaid recipients who are considered most capable of working. For the most part, we are talking about the single, childless, able-bodied adults who became eligible for Medicaid under the ACA’s expansion of the program.
A federal judge late last month said the Trump administration was wrong to allow Arkansas and Kentucky to add work requirements to the expansion population because some people might lose their Medicaid coverage.
Alex Azar, who as secretary of Health and Human Services approved the waivers, had cited four reasons for doing so; three of them were related to improving health outcomes for those covered by Medicaid.
But Judge James E. Boasberg — getting back to the point of the law — ruled that improving recipients’ health outcomes was not a primary purpose of Medicaid. Dating back to the law’s passage in 1965, Boasberg maintained, Medicaid’s primary purpose was simply to cover people who can’t afford health insurance on their own.
In other words, it matters less under Medicaid that recipients are healthier than that they are covered — that they merely have an insurance card in their pockets, as those promoting full expansion in Georgia like to put it.
Surely, however, the point of a law like Medicaid should be to improve the health of beneficiaries. In fact, much of the recent impetus behind Medicaid waivers has been to address the poor health outcomes we get for the almost $600 billion spent on it each year.
For example, the Oregon Health Insurance Experiment, which compared those who gained Medicaid coverage through a lottery to those who didn’t, found there were “no statistically significant effects on physical health” for the new enrollees. They went to the doctor more, were better off financially and less likely to suffer from depression. But they did not improve a range of key health indicators.
Even if we assumed coverage was mostly about access to health care, and that it was beyond the ability of any program to improve people’s health beyond ensuring they could see a doctor, Medicaid falls short. Patients are significantly more likely to find a doctor who will see them if they have private insurance.
One would like to think lawmakers on both sides of the aisle would support changing the law to make clear that improving health outcomes is an important purpose of Medicaid. But that seems unlikely for now, given that Democrats in Congress are putting their energy behind yet another coverage-driven law with their various single-payer plans.
It might have been reasonable in 1965 to assume that coverage would lead to better health. Experience proves otherwise. From the U.S. Capitol to the Gold Dome, lawmakers need to consider whether Medicaid’s main purpose — at least according to one federal judge — makes the program in its current form worth any additional investment.