Presentation on theme: "Harold Pollack Helen Ross Professor of Social Service Administration, University of Chicago Adjunct Fellow, Century Foundation."— Presentation transcript:
Harold Pollack Helen Ross Professor of Social Service Administration, University of Chicago Adjunct Fellow, Century Foundation
ACA, including its Medicaid expansion, arguably most important public health measure in five decades. More important HIV policy than the National AIDS policy. More important substance abuse policy than the National Drug Strategy Both big provisions and fine print extremely important Many stakeholders have reasons to regret imperfections and compromises in ACA. Less so in public health.
Consider predicament of “typical” substance abuser, homeless person, extremely poor person in much of U.S. circa July 11, 2012. Who will pay for his substance use treatment, or the treatment of physical health comorbidities? Right now, he’s Medicaid ineligible in most states. He’s not a mom. He’s not a veteran. He has no health condition that qualifies as a federally- recognized disability for purposes of SSI or SSDI. He does not have AIDS (though he might have contracted HIV). His services financed through a patchwork of safety-net programs and (often) uncompensated care.
In 2014, he will become Medicaid-eligible simply because his income is below 138% of the poverty line. Important to finance substance abuse treatment and other services to that individual. Such expanded eligibility also important to the institutions and payers that assist that individual or provide safety-net care. Critical issue for city and county governments, that often bear burdens caring for uninsured. ACA also includes critical language expanding coverage of SA/MA issues—and at parity.
National Federation of Independent Business v. Sebelius constrained federal power in new way, and opened new choices for states. States may now decline to participate in Affordable Care Act’s Medicaid expansion. The full implications of this decision have yet to be felt—both within Medicaid and in the broader contours of state-federal relations.
“Put up or shut up” moment for many governors and state legislators. ACA offers states (over time) roughly 19:1 federal matching funds to finance services often provided through public sector. $50 billion in the case of Texas, requiring $2.4b from state. Many constituencies have strong stake in Medicaid expansion. First VA then Medicare history encouraging in desegregating southern hospitals. Early Medicaid history also encouraging. The real financial hit to some states is not ACA expansion, but high takeup among those already eligible.
Substantial implementation challenges Supreme Court decision shifts bargaining power between states and the federal government. Misplaced panic over Medicaid quality, cost, fiscal burdens, and anticipated growth
Cutting Medicaid costs requires either painful cuts to elderly, blind, and disabled, OR cutting off coverage for tens of millions of low-income working age people.
Medicaid proposals shifting costs and risks onto individuals and onto states Bloc granting Medicaid, with bloc grants rising slower than costs of care. “Repeal and reverse” a serious challenge to structure of program. Raising federal share of existing Medicaid burden a better response to concerns/failures at state level. But that would be a different talk.