Make Medicaid Great Again

I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle. At first the punditocracy was silent, then the fear-mongering began about 2 days after election day. And now there is a deluge of mostly panic pieces, with some general fluff crystal-balling out there.

Here’s a few thoughts:

1) The sky is not falling, but there is rain in the forecast. Although you wouldn’t know it as the 4th estate continues their delusional narrative with headlines like these: “Millions could lose coverage under Trump plan,” “Trump victory worries KY Medicaid advocates,” and “Gov. Edwards hopes Medicaid Expansion isn’t at risk under a Trump presidency”. Medicaid will change, as it always does (I have a chart showing major changes in Medicaid over 50 years and its full). And we likely will see a rebalancing towards cost control as opposed to the spending orgy of the past 20 years (but its free federal money! They print the stuff!). The go-to answer of spend more money, like Death-Star-construction-budget amounts of money, probably is weakening. And that’s a good thing. We need to think harder and come up with additional strategies besides additional spending.

Which brings me to my next assessment-

2) Reducing or beginning to limit Medicaid spending growth will force states to prioritize like never before. It will change the current highly conceptual “value-based care” paradigm to one in which there are real winners and losers based on risk ultimately tied to performance (not just symbolic tiny percentages based on who had the best data, marketing or lobbyist). This is what those of us who love Medicaid because it helps those in the most need truly want. Medicaid has had fundamental and terrible issues for decades. We need disruption in Medicaid. But we are all so accustomed to looking the other way on the waste and fraud- which is way bigger than anyone thinks, just read the fraud follies each week- and that’s just what I happen to find in the press – that we are almost entirely unequipped to look at Medicaid in an honest, constructive way. We don’t even have the words to criticize it in our language- Medicaid is the great untouchable policy idol in our lives. We are so practiced in defending it with sometimes ridiculous theories that we end up with nothing but weak defenses that just get us through the next budget cycle. And Medicaid always grows in those state level budget discussions, even when education and roads and parks and other things do not (we just robbed the AL coast of BP oil-spill money here to fund one more ride on the Medicaid carousel next year). We do this (fight for more Medicaid funding) because we care about the populations, but we have become intellectually lazy as we swim in oceans of money. We can do better.

It may well be that, after finally forced to do so, all of us actually with some ability to fix it (consultants, health plan management, providers, agency officials), may be motivated to do just that.


But lest you be encouraged, here’s number 3-

3): The foggy delusion that more money is the answer will likely continue, and most in our Medicaid world will not rise to the challenge. Instead we will dig in our heels and look for ways to resist the change. We will wait and only react to whatever is “done to Medicaid” by that mean-ole’ GOP. Perhaps the best opportunity to really improve outcomes for Medicaid members to come our way in 50 years will be met with fierce opposition disguised as virtuous panic. So what will be done with Medicaid, the reason you have read all these words to this point (and either loved me more for them or decided to finally set aside the RoundUp after all those years of reading in secret guilt) is the subject of number 4-

4): A very large Pause Button is being pressed. In February it will be a pause on all the late comers to expansion. Between now and late January, it will be the Fast Forward button on any of those waivers seeking to trim back expansion (hurry up and deny them, like CMS did with NH’s request a few weeks back). When the Pause is over (likely around Q3 2017), we will see Medicaid transformation as part of federal repeal and replace efforts. Expect block grants or something like them. Expect it to be a fight, and expect there to be some sort of compromise but not 50-50.

Regardless of what 2017 brings for our Medicaid world, I can safely predict this will be the most exciting time to be in Medicaid in the history of the program. For those afraid, find the fire in your gut to fight whatever you perceive as the danger. For those able to peek past the fear, pursue the opportunity to improve this critical program like never before.

Onward and Upward!