Medicaid should be abolished. But that's not the case! – Healthcare Blog
Matthew Holt
Long time ago, in a different country, there was a landslide election for a crowd seeking change. They got it. Americans have been running for national health care since 1917. There were failures in 1933, 1946 and 1961. But in 1965, they got it. Something
But something strange happened to Congress. From the political sausage making, there is a plan to “care” plans over 65 years old. Another plan is to “help” the poor. (Stolen from the wonderful Adimika Arthur). Strangely, the Medicare program used to be a federally funded program. Medicaid is a national management program, even if it is funded by at least the Federal Reserve.
This means Medicaid is always vulnerable to state whimsical attacks. Of course, many states have demonstrated records of how the poorer and minority populations were treated in the past (think slavery, Jim Crow, KKK, independent schools, drinking fountains, buses…you get it).
So while Medicare became anyone after 65 years of age, Medicaid was later a program for those with disabilities or with kidney disease, and later was not well treated. (Stolen from Jonathan Cohn). Now, in 2025, it is again under serious threat.
Before reaching this threat, it is worth looking into the program. Medicaid has evolved and now covers most nursing home care (for the “poor” older people), providing care for people with disabilities, and even paying Medicare B Part Part Premiums for Site Food and unable to pay. It also covers health insurance for poor people under 65, which is a considerable number in states that receive the ACA Medicaid expansion. Of course, these people are imaginary people that make them too poor to buy in the communications established by the ACA. Usually, Medicaid includes the CHIP program, an insurance program covering children under impoverished by Clinton in 1997.
This old KFF chart shows that while 75% of Medicaid people are poor, but less than 65 years old, are not classified as disabled, 50% of that money goes to those that don’t.
All this leads to a Bizarro world where there is a federal government plan for people over 65 years old and then a completely different state government plan that uses 1/2 of its money to people over 65 years old and disabled people. return In the federal plan. This is stupid, always.
Of course, there are more.
Many states that do not share alliance heritage do a lot with Medicaid. For example, Oregon has been trying to increase coverage in different ways and spend money on community care. Physicians and three-time Oregon Governor John Kitzhaber are very voiceful about what they did before the ACA and how Medicaid should change to reflect these new realities.
Since 2012, under the 1115 waiver, Oregon Medicaid has been provided through the new Coordinated Care Organization (CCO) (CCO), a community-based organization responsible for providing quality care while also focusing on community health. They are based on global budgets and each year the growth rate of membership is lower than medical inflation. CCOs are also required to maintain enrollment and benefits while meeting strict indicators around quality, outcomes and patient satisfaction. During the first 5-year exemption period, Oregon recruited another 384,000 people and operated at each member growth rate each year each year. All CCOs meet the required quality and outcome measures and achieve a net cumulative saving of $1.1 billion.
In fact, Oregon is by no means the only state that has done different things. California's massively expanded coverage after the ACA has now 15 million people or more than their population are using Medicaid. As a result, a lot of experiments have been performed in the program. This 1115 exemption is a 1115 exemption that spent the federal funds as unconceived in the 1965 Act, working overtime at the state and county levels in the Golden State. The overview is that Medicaid here has been changed to a more comprehensive program called Calaim (Forward and Innovative Medi-Cal in California), which covers a wide variety of things rather than traditional Medicaid, including Duras, community health workers (and possibly barbers!), and housing and food in some counties.
Despite these improvements, I don’t recommend that you deliberately move to Oregon or California and become poor. (Stolen that line from my late boss Harris, Bob Litterman)
But nationwide, a lot of things have happened to Medicaid. Since the 1990s, most care has been turned to private health programs, although many people run publicly. But Centene and Molina have built very profitable businesses in particular in a similar way to how United, Humana, etc. mined Medicare Advantage.
While not strictly speaking, operating through Medicaid itself, we have also established many other sources of funding for safety net providers. This includes the 340B program that hospitals use to make money on medication, to pay for hospitals to treat more poor people, and then providing FQHC with about $35 billion in federal funds that treat many uninsured and Medicaid populations.
Therefore, we have established an incredible swelling procedure. It is managed primarily by organizations in business or county plans that do not look like ordinary Americans get insurance from it. These programs are networks that get most of the funds from Medicaid from the Facilities Network (FQHC, County Hospital, etc.), or use many other methods to raise funds. These providers don’t look like or share many customers with the average doctor and health system where most employed Americans or Medicare are cared for.
And you think it was separate but was abolished in the 1950s!
Of course, Medicaid is under great threat, just as the ACA is to some extent. The Trump administration has lingered in the literal form of a South African immigrant and a symbolic chainsaw, which has promised cuts. The most common number suggested is $880 billion in 10 years. Now, this is a big part. $90B – Annual Equivalent Number – About 15% of federal spending for the program. Of course, it's a plan that spends a lot in the red state, but of course, most of the spending in the red state is on black and brown people, and many white Trump supporters are unaware that it also covers many white political allies. Wendell Potter and Joey Rettino noted that given that many states call it different Medicaid, in red states, a group of low-information voters who voted for Trump may not realize it covers them!
Even so, in a thin program like peanut butter, a 15% reduction and a low fee already paid to providers and nursing homes will be a hassle.
Another issue is about regulation. Those ubiquitous 1115 exemptions allow many procedures that are not in the original regulations, and of course, getting or renewing exemptions from new HHS and CMS can be tricky. To be sure, Republicans are obsessed with ensuring that anyone who is Medicaid is working. During the last Trump administration, these “job requirements” were introduced in several states. They end up saving money and honing unnecessary. But given the current government’s desire to be as cruel as possible, there is a good chance that ideology will win here and there may be a job requirement or other stupid shit imposed in every state.
So the current battle will be the Blue Country Dems trying to keep Medicaid. Well, how this is manifested when some of them realize it, and whether the player can hold their thin majority together.
But that's not what we should do with Medicaid. Instead, we should take the risk, the Clintontons tried to accept, but Obama and the ACA avoided it.
We should not reform or approve Medicaid. We should abolish it.
Instead, we should use this Medicaid to create the proper universal healthcare system and put people on the same financial and delivery platforms as Medicare and Medicare and commercial insurance. Whether we do this in the multipayer world like the Japanese and Germans, a major single payer version like the French or Taiwanese, or a state-owned system like the UK and Sweden, it removes the second category of health care status for citizens who do not have Medicare or good private insurance. Furthermore, this will enable our clinical professionals to practice medicine in their young and idealistic ways without worrying about how much each patient pays because they will get the same amount regardless of who they are accepting.
Let's let the political momentum argue about equal treatment for all Americans, rather than the welfare program that emerged around the political mistakes of 1965.
Matthew Holt is a publisher of THCB
