The Washington PostDemocracy Dies in Darkness

The Health 202: 'Medicare for all' is the dream. 'Medicaid for more' could be the reality.

with Paulina Firozi


"Medicare for all" is the hottest position on the left these days, but there's a quieter push afoot to create a public option using Medicaid. 

Chanting "Medicaid for more" may not sound as bold for progressives seeking to prove their bona fides before the midterm elections. Yet all the most-hyped 2020 Democratic presidential candidates are on board with the idea, including the Medicare expansion's biggest champion, Sen. Bernie Sanders (I-Vt.). 

The idea in concept is simple: Allow states to open up their Medicaid programs to anyone regardless of income. Those people could buy in to the social safety net and have access to Medicaid's provider network and benefits. The groundwork for expanding the program for low-income Americans has already been laid to some extent as 34 states have expanded Medicaid under the Affordable Care Act.

Sen. Brian Schatz (D-Hawaii) has introduced the "State Public Option Act" to promote states to expand Medicaid — co-sponsored by some familiar Democratic faces: Sanders, Elizabeth Warren (Mass.), Cory Booker (N.J.), Kamala Harris (Calif.) and Kirsten Gillibrand (N.Y.). But the real efforts are happening at the state level where legislatures all over the country are seriously considering the idea. 

Heather Howard, a lecturer at Princeton University who also helps states with their health-care systems, said many plans are in their infancy, but that 14 states across the country have made moves to, at minimum, weigh the benefits and challenges of shifting Medicaid to a publicly available health insurance option. 

"There are a lot of policy considerations to think about, but while the federal policy debate is stalled, you have states thinking about what tools do we have. [Medicaid] is the immediate tool you have," she told me. 

That's because Medicare is operated at the federal level so any major changes to it have to be decided in Washington. Medicaid, on the other hand, is run by the states, so they have more discretion over how the program is set up. 

There are real critiques of Medicaid as it now exists, such as low reimbursement rates for doctors and uniform access to care. To offer it to everyone would require responding to those criticisms as well as new questions such as the cost to states, whether states have to apply for federal waivers to alter the program and whether a public option lives on or off the ACA exchanges.

This week stakeholders across New Mexico met with President Obama's former Centers for Medicare and Medicaid Services Administrator Andy Slavitt to begin some of those conversations. Earlier this year, New Mexico's state legislature passed a bill to create a committee to study a Medicaid buy-in program. Medicaid is popular there; one-third of New Mexicans are enrolled. Yet 230,000 people remain uninsured in the state, according to Kaiser Family Foundation data, and proposed premium rates for 2019 for those who don't qualify for ACA subsidies are increasing anywhere from 9.2 percent to 18.5 percent. 

Slavitt is the board chair of a new group, United States of Care, which has an impressive roster of bold-faced names leading it from investor Mark Cuban to former Obama speechwriter Jon Favreau to former congresswoman Gabrielle Giffords (D-Ariz.) and her astronaut husband Mark Kelly. In the absence of Washington leadership, the group is working with states on ways to improve health care. 

Allison O'Toole, the group's director of state affairs, was also on the ground in New Mexico this week and told me there's a "real hunger" and "momentum" around the idea of allowing states to expand Medicaid.

"Washington is in gridlock and not addressing people's real concerns around the cost and affordability of health care," O’Toole said. "This has created a greater sense of urgency and necessity by states to pick up that ball and run with it."

With the Republicans' failure to repeal the ACA and the public outcry when they tried, Democrats are feeling emboldened this year to talk ambitiously about their health-care goals. 

Health care is a leading issue heading into November, and polls show at least half of Americans are in favor of a "Medicare for all" program. But even if Democrats win the House majority and make gains in the Senate, President Trump has said Obamacare is unsustainable and his administration has worked persistently to chip away at it.

That's why Michael Sparer, a public- health professor at Columbia University, believes "Medicaid for more" is not only good policy, but also good politics. It's the type of proposal, he reasons, that could peel off moderate Republicans in a way that a national Medicare program never could. 

It's true that Medicaid is a favorite GOP punching bag. The Trump administration is urging states to add work requirements to their programs and the GOP playbook has long included capping how much the federal government pays each state to administer Medicaid. 

Yet 34 states, including many with Republican governors, expanded the ACA under Medicaid to include more low-income residents, and several more red states are on the precipice of following them. It's a program that has endured and grown for 53 years.

"The Medicaid buy-in is more of a compromise program, it’s not viewed as a big national program. People who believe in states' rights can view it as states having more flexibility," Sparer said.

Sparer has written extensively on the topic and told me his support for expanding Medicaid is heavily influenced by the political viability of focusing on the program for low-income Americans versus the one covering seniors -- meaning states don't have to wait for a new president to do something meaningful. But that doesn't mean he thinks national political figures like Sanders should stop talking about "Medicare for all."

"The advantage is [Medicaid buy-in] is incremental, it adds populations here and there. But incremental isn’t a great political slogan. You put 'let’s change the system' on a bumper sticker and I get that," he said. "But the more there’s momentum for 'Medicare for all,' then 'Medicaid for more' could be the back up plan."

"Given the ever-present debate," he added, "a more incremental path is a better path."


AHH: A new lawsuit filed today by the cities of Chicago, Columbus, Cincinnati and Baltimore is charging that the Trump administration’s efforts to dismantle the ACA violate the Constitution.

The lawsuit claims Trump has “waged a relentless effort to use executive action alone to undermine and, ultimately, eliminate the law,” an effort violating Article II of the Constitution to “take care that the laws be faithfully executed,” NBC News’s Heidi Przybyla reports.

Columbus City Attorney Zach Klein told Heidi there’s a “clear case of premeditated destruction of the Affordable Care Act.”

“The suit also cites Trump scaling back oversight of insurance issuers, cutting open enrollment in half, urging a federal court to throw out Obamacare’s protections for pre-existing conditions and undermining the individual mandate,” Heidi writes. “All of these actions, they say, undercut confidence in the program and enrollment, the keys to its success.”

OOF: A new study suggests that childhood cancer survivors are struggling with the long-term consequences, or “financial toxicity” that may cause them to delay or skip necessary medical screenings or medications because of the economic burden. The research from St. Jude Children’s Research Hospital also said survivors could have employment disruptions or problems with their insurance if they had complications from earlier caner treatments, our Post colleague Laurie McGinley reports.

I-Chan Huang, the lead author of the study published Wednesday, told Laurie such financial consequences are “more widespread among pediatric cancer survivors than among survivors who were diagnosed with cancer as adults.”

Kristi Lowery, who participated in the study, said she pays $12,000 every year out of pocket to pay for medical care following a childhood diagnosis of Ewing sarcoma and later development of breast and thyroid cancer as well as heart and lung problems, Laurie reports. “It’s a huge financial burden,” Lowery said. “I definitely could be putting that money into my retirement plan or not taking out college loans for my son.”

OUCH: Check your refrigerators. And your lunchbox. The U.S. Agriculture Department issued a warning yesterday not to purchase dozens of salad and wrap products from stores including Kroger, Walgreens and Trader Joe’s.

The agency is warning that beef, pork and poultry in certain salads may be tainted with intestinal parasites, our Post colleague Alex Horton reports. The parasite, known as Cyclospora cayetanensis, can cause non life-threatening symptoms including diarrhea, vomiting and fever, and is the same parasite that was responsible last month for a nationwide outbreak linked to McDonald’s salads, according to the Centers for Disease Control.

“The outer limit of the incubation period for this batch of food is Aug. 6, USDA said, and it could be up to six weeks before officials begin to receive reports of illness,” Alex writes. “It is not clear whether any illnesses have already been reported from ingesting products linked to the newest warning.”


— President Trump has made 288 false or misleading statements related to health care since he took office. Just this week so far he's made six. 

These stats come courtesy of the Post fact checker team's interactive daily tracker of claims made by the president. As of Wednesday, after 558 days in office, Trump had said 4,229 untrue things, which amounts to approximately 7.6 a day. 

Most of Trump's health-care falsehoods this week were made at a Tuesday night campaign rally in Tampa. Here's what the president said there and how our fact checkers debunked them:

TRUMP: “We signed choice [for veterans] and we did somebody that nobody thought. That’s when you stand in line for weeks and weeks and weeks ... [to see a doctor] and they’re just not there. They’re able to go out and get a private doctor.”

FACT: Despite Trump’s claims, veterans are still facing long wait times. A 2018 report by the Government Accountability Office found that veterans referred to Trump’s “choice” program “could potentially wait up to 70 calendar days” to be seen by a doctor, which is not consistent with the requirement that they receive care within 30 days. On average, the study found veterans using the choice program wait 64 days.

TRUMP: “In fact [Obamacare] was gone until one gentleman decided at 2 o’clock in the morning.”

FACT: Trump suggests that Sen. John McCain's vote was the only impediment to passing a repeal and replacement of the Affordable Care Act. But none of the substantive replacement bills got nearly enough votes, and McCain's vote was against a "skinny" repeal that was only to lead to talks with the House on a common position, with no guarantee of an agreement that would pass both Houses.

TRUMP: “Obamacare has been a totally disastrous situation.”

FACT: Credible estimates suggest the health-care law boosted the number of people with health insurance by 20 million. The Congressional Budget Office said that the individual market would be stable in most markets at least for the next ten years under the Affordable Care Act, though the Trump administration has taken steps to weaken it that have raised premiums.

TRUMP: “We repealed the core of Obamacare. You know the individual mandate.”

FACT: This is wrong. Eliminating the individual mandate may weaken the Affordable Care Act, as it may lead to risk pools that are less healthy, but it does not wipe out the law.

TRUMP: “We’re doing great on health care. We’re allowing Americans to buy better health care for less money through association health plans including across state lines.”

FACT: Trump is wrong. The new association plans have not be sold yet. Most health-care experts say they will offer substandard insurance.


— The Centers for Medicare and Medicaid posted Wednesday all the proposed 2019 insurance rates for ACA-compliant plans. All the premium requests will need to be approved by state regulators, but it's an early peek at anticipated rates. 

Digging into the numbers, the Wall Street Journal found that many premium increases were less than previous years and some were even reduced. 

"In some states, the shift is particularly extreme: Blue Cross Blue Shield of Wyoming, the lone ACA insurer in that state, is seeking a 0.27% average decrease for 2019, after a 48% jump in its premiums this year," the Journal reports. 

While the Trump White House's changes to ACA requirements are impacting some insurers' projections, Steve Ringel, president of the Ohio market for CareSource, told the Journal that "the marketplace is stabilizing."

The CMS data is public and searchable so any consumer can look at their plan's rate proposals. To do so, go to this link and enter your state and the date range: 01/01/2019 - 12/31/2019.


— Senate Republicans failed Wednesday to pass an amendment blocking the nation's capital from creating its own individual mandate. 

The District of Columbia voted to implement its own mandate after Congress eliminated the ACA requirement that everyone have health insurance or pay a penalty. Led by Sen. Ted Cruz (R-Tex.), GOP senators tried to add the language to a government funding bill, but a slim majority voted to table it, The Hill reports. 

Cruz said doing so was "voting to raise taxes on low-income D.C. residents who are struggling to make ends meet." Sen. Patrick Leahy (D-Vt.) countered that allowing the amendment to proceed would be saying to D.C. that the federal government would tell them what to do. "That's not democracy," he said. 

However the debate's not over. The House GOP did add such language to the funding bill it passed, so there will be a renewed opportunity for Republicans to try to get the language into a final appropriations package when the two chambers negotiate their competing versions. 


— The Trump administration announced its final rule Wednesday morning to allow people to buy short-term health plans and extend them up to three years. And the insurance industry expressed  its concerns while companies selling those short-term plans watched their shares rise. 

America’s Health Insurance Plans President Matt Eyles said in a statement that his association is "concerned that consumers who rely on short-term plans for an extended time period will face high medical bills when they need care that isn’t covered or exceed their coverage limits."

Blue Cross Blue Shield Association issued a similar warning that the new rule "has the potential to harm consumers."

But shares of eHealth and Health Insurance Innovations, two companies that sell short-term plans, rose in response to the news, CNBC reported. 

— Meanwhile, the New York Time's Margot Sanger-Katz laid out all the things a consumer should know before choosing a short-term plan. It's been well-established that these plans aren't bound by ACA's required benefits or its protections for people with preexisting conditions. But Sanger-Katz also writes that a short-term plan can cap how much it will pay for your care, so if you're stricken with an expensive illness and go over that amount, you could be without coverage. She also pointed out some stranger exclusions, such as a plan in Illinois that only covers hospital stays that begin during the week. 

— Billionaire investor Carl Icahn is expected to oppose a planned Cigna Corp. merger with Express Scripts, the nation's largest pharmacy benefit manager, the Wall Street Journal first reported. 

Icahn, who is a stakeholder in Cigna, is reportedly afraid that when Amazon enters the health-care space it will dilute Express Scripts' value. He's also fearful of a Trump administration proposal to limit drugmaker rebates to pharmacy benefit managers.The WSJ reports that Icahn is trying to convince other stakeholders to oppose the $54 billion deal. 


— A new study suggests public-health efforts to combat the ongoing opioid crisis may not be as successful as you’d think. The research found the use of prescription opioids drugs not only remained high in the United States over the last decade, but the dosage number for adults getting the drugs has continued to increase and is particularly high among patients with a permanent disability, Reuters’s Linda Carroll reports.

The research looked at a national database of medical and pharmacy claims for opioid use among 48 million insured people between 2007 and 2016, including working-age adults with commercial insurance and Medicare beneficiaries, Linda reports.

The study found 52 percent of disabled Medicare beneficiaries, 26 percent of older Medicare beneficiaries and 14 percent of commercially insured patients had used opioid medication during the given period.


— A new Ebola outbreak has emerged in the eastern Democratic Republic of Congo, with four people testing positive for the disease, Congo’s health ministry said yesterday.

Just last week, the World Health Organization announced the Ebola outbreak in the region was officially over, but WHO officials were again moving resources into the area yesterday, Reuters’s Fiston Mahamba reports. Already, 20 people have died from hemorrhagic fevers in an around the densely populated town of Mangina, according to the health ministry, although it is not known when.

This would be the 10th Ebola outbreak in central African country since 1976. Officials are not yet considering the use of the same Merck-developed experimental vaccine that helped with the rapid response with the 9th outbreak, as there has not yet been a confirmation of the exact strain of the latest outbreak, which WHO is noting is “presumptive Ebola.”

— The Delaware general health district has received more than 500 inquiries (95 emails and 423 phone calls) related to potential customers who may have been affected by a food-born illness outbreak at a Chipotle Mexican Grill restaurant in Powell, Ohio.

There have been 200 people who have so far reported nausea, diarrhea and fever in interviews with health department staff, CNBC’s Sarah Whitten reports, and the department will be testing for salmonella, shigella, E. coli, and norovirus, as well as for two different bacteria, bacillus cereus and clostridium perfringens.

— And here are a few more good reads: 

Trump is trying to decimate Obamacare. But that has proved hard to do. (Amber Phillips)

Senate defeats move to protect vegan milk (Washington Examiner)


Missouri Obamacare insurers raise and lower rates for 2019 (Washington Examiner)


Abortion-rights activists brace for new wave of restrictions (Associated Press)


Coming Up

  • The U.S. Food and Drug administration holds a joint meeting of the “Drug Safety and Risk Management Advisory Committee and the Anesthetic and Analgesic Drug Products Advisory Committee” on Friday.  

White House announces support for 1988 plastic gun law:

White House press secretary Sarah Huckabee Sanders on Aug. 1 said President Trump supports the 1988 law barring wholly plastic guns. (Video: Reuters)

White House press secretary Sarah Huckabee Sanders called insults shouted at CNN reporter Jim Acosta by President Trump’s supporters “freedom of speech:"

Press secretary Sarah Huckabee Sanders on Aug. 1 called insults shouted at CNN reporter Jim Acosta by President Trump’s supporters “freedom of speech." (Video: Reuters)