Right On: Here’s a start on Medicaid reforms

Medicaid reform. Undated. | Image courtesy Pixabay, St. George News

OPINION — When a conservative proposes changes to a program loved by liberals, expect biblical-scale weeping and gnashing of teeth. For liberals, any change that might limit benefits, no matter how modest and reasonable, puts a beloved program on a slippery slope to oblivion.

Medicaid cries out for reform. What started out as health care for impoverished women and children is now the third-largest program in the nation’s budget and its fastest growing. It covers over 70 million people, 1 out of 5 Americans.

Scary thought: Single-payer health care is closer than you think.

Three Medicaid reform proposals offer a modest start at taming this runaway entitlement. All are threatened by knee-jerk liberal reactions to even the slightest hint of restraint.

First, Medicaid needs the same work and job training requirements that federal welfare has had for decades.

Obamacare expanded Medicaid to healthy, working-age adults above the poverty level. Many of these folks work in low-paying jobs without employer-provided health insurance. Medicaid became their fallback.

So far, so good. But what about Medicaid recipients who are not working?

As reported in St. George News in January, the Trump administration proposes to allow states to impose work or job training requirements on unemployed, working-age Medicaid recipients without disabilities and without dependents.

The new guidance is intended to encourage “work and community engagement” among able-bodied adults and “help individuals and families rise out of poverty and attain independence in furtherance of Medicaid objectives.”

Welfare programs should be judged not by how many people are enrolled but by how many former beneficiaries no longer need them.

Liberal reaction was predictably shrill and mirrored their reaction to federal welfare reform in 1996. Recall that Republicans imposed similar work or job-training requirements on federal welfare recipients. Liberals howled. President Clinton signed the bill anyway saying, “Today, we are ending welfare as we know it.”

Looking back, even the liberal Atlantic magazine acknowledges that “by the numbers, welfare reform was a success.” Nonetheless, in typical liberal fashion, the magazine goes on to complain about those who’ve fallen through cracks in the safety net.

Liberals are willing to spend billions on the unqualified to ensure that not one worthy recipient is overlooked. As a result, billions are squandered.

Responding to Trump’s initiative, a bipartisan majority in Utah’s legislature passed a bill in early March to take advantage of this opportunity. The state will seek federal approval to expand Medicaid coverage to as many as 60,000 able-bodied Utahns provided they seek jobs.

A second reform – auditing current recipients for eligibility – has the potential to save billions while not reducing benefits for even one of today’s eligible participants.

The bright blue state of Oregon demonstrated both how government entitlement programs are routinely abused and pointed the way to dramatic cost savings.

In an audit of Medicaid recipients, Oregon found that almost half of those it checked no longer qualified. The state had given $191 million in health care benefits to these folks. You and I helped pay for this entitlement failure since our federal taxes cover about 75 percent of Medicaid costs for all states.

Extrapolate Oregon’s experience to the country at large and we’re talking savings in the $20 billion range.

Turn now to a third, more difficult reform: ensuring Medicare doesn’t add to the nation’s opioid epidemic.

Medicaid offers cheap access to pills that can be resold on the black market. For as low as a $1 co-pay Medicaid beneficiaries with complicit or unwitting doctors can get up to 240 oxycodone pills that can be resold for $4,000.

As reported by the Senate Homeland Security and Governmental Affairs Committee, since 2010 more than 1,000 people across the country have been charged with or convicted of improper use of Medicaid to obtain prescription opioids.

The Senate committee found that the problem seems to be worse in states that expanded Medicaid as part of Obamacare. More than 80 percent of nearly 300 cases were filed in Medicaid expansion states with New York, Michigan, Louisiana, New Jersey and Ohio at the top of the list.

Moreover, “the number of criminal cases increased 55 percent in the first four years after Medicaid expansion, from 2014 to 2017, compared to the four-year period before expansion.”

Doctors who treat Medicaid patients prescribe a disproportionate share of opioids. Finding out why could go a long way toward reducing the opioid epidemic plaguing the country. Opioid addiction treatment center fraudsters continue to prey on low-income addicts and then bill Medicaid.

These findings don’t prove Medicaid causes these problems. Illicit fentanyl and heroin cause most opioid deaths. But any Medicaid contribution certainly warrants a careful review by the Health and Human Services Department and by outside researchers.

President Trump’s bipartisan Presidential Commission on Combating Drug Addiction and the Opioid Crisis offered 56 recommendations, all of which he accepted.

One of the commission’s goals: reducing opioid prescriptions by one-third nationwide. A common sense step in that direction is removing questions about pain on patient surveys “so that providers are never incentivized for offering opioids to raise their survey score.”

Opioids are a tough problem with no easy solutions, but one clearly deserving nonpartisan attention.

Medicaid, coupled with its larger entitlement sisters, Social Security and Medicare, is on a collision course with fiscal reality. But of the three, both politically and practically, Medicaid seems to offer the best prospect of matching its goals to what the country can afford.

These three proposals are a modest start.

Howard Sierer is an opinion columnist for St. George News. The opinions stated in this article are his own and may not be representative of St. George News.

Email: hsierer@stgeorgeutah.com

Twitter: @STGnews

Copyright St. George News, SaintGeorgeUtah.com LLC, 2018, all rights reserved.

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4 Comments

  • bikeandfish March 22, 2018 at 9:26 pm

    As a person with long term health problems, though not covered by medicaid, the notion of removing pain questions from randomized patient surveys seems unnecessary. As stated in the link, HHS has already removed relevant questions from “calculations of incentive payment”. The other questions by that logic do not affect CMS incentive payments but likely give important information about how patients are being treated for pain. We are finally at a point in society where we treat pain as an important component of health and I can tell you that is a critical change in healthcare. Pain can drastically affect healing and recovery and has a tremendous impact on quality of life. Pain management and assessment should be part of every healthcare patient assessment. We clearly want to eliminate the opiod epidemic but altering the quality of care for all patients because of the relatively few that abuse opiods seems to swing the pendulum too far. There are plenty of other pain management methods that can be utilized, many hospitals already are, without completely abandoning “the expectation of eliminating a patient’s pain as an indication of successful treatment, and seeing pain as the fifth vital sign,” as stated in the commission’s report.

    The fact is helping patients manage and eliminate pain is likely to expedite recovery, decrease medical expenses and hasten a return to self-sufficiency, the very goals many like the author claims to value. As someone who has experienced weeks of excruciating pain, 10 on 10 scale, I can tell you viewing it as a fifth vital sign was a massive benefit to my life.

  • commonsense March 23, 2018 at 8:21 am

    The problem with using pain as reason for Medicaid is that pain is subjective.
    To some, working is painful, even living is painful. And, considering pain as a vial sign is problematic since it can’t be quantified. I know people who work despite intense migraine headaches while others others consider themselves incapacitated.

    There are countries in Europe that require government service work in order to receive any entitlement. Even people in wheel chairs are required to sort mail of water plants before they get their benefit.

    It’s time to end generational welfare abuse. A job can take your mind off of your pain and off of your dependence on working Americans overburdened with taxes. Medicaid abuse flourished under Obama and needs to be curtailed.

    • bikeandfish March 23, 2018 at 11:11 am

      I am not against Medicaid reform but the incentives for the relevant pain questionnaire have been removed so those remaining are solely informative for patient care. And yes, “pain is subjective” but that is inherent with any focus on the individual, ie the subject/patient. Once we get outside of population stastical analysis everything is subjective and focused on the individual and their quality of life. Yeah, we can objectively measure BP, heart rate, etc but those numbers become subjective when applied to individual patients. But we know addressing these issues as symptoms, including pain, can have measurable impacts on a patient’s quality of life nonetheless, even if it takes trial and error.

      The notion that the focus on pain management should be the focus of opiod abuse is a lazy shortcut for doctors. Its not pain assessment that is the problem but how doctors, hospitals, and insurers manage it and prescribe medication. Opiods should not be the first line of defense for all or most issues. We can manage pain with other medications, techniques and lifestyle changes. On the other hand, folks like me may need narcotics for pain management but we should be assessed and educated on the possible side effects. I was and use my pain killers sparingly, like once a year because of potentially horrible side effects.

      But that means teaching doctors more about pain management, training hospital staff in alternative techniques and medications (ie not just heavy meds like opiods) and challenging insurance companies to cover those modalities. That is comprehensive reform. Just eliminating questions does nothing to benefit the patient.

      A citizen’s pain management is a choice between the patient and the doctor, no matter if they are on Medicaid or employer’s insurance. And we have already removed incentives regarding pain assessment so it doesn’t factor into financial reform issues. We can reduce Medicaid abuse and the opiod epidemic without penalizing patients who just want high quality professional care.

  • John March 23, 2018 at 10:53 pm

    If a Doctor is over prescribing opiods, with all the checks, balances and paperwork that are in place today it will show up and he should be looked into, it’s all on computer. The major cause of opiods in the streets is the black market.. The pills are being smuggled in from Mexico and China to be sold on the streets. That is where the solution lies. Cut off the illegal supply ! But there are too many in the upper levels of government who choose (for whatever reason) to look the other way, fight against border security and claim illegal sanctuary cities , where these illegal drugs are sold like candy. “If it isn’t broken, the liberals haven’t tried to fix it yet”

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