Posts About Medicare

During this Older Americans Month, we want to pay tribute to a leader with whom many Health Policy Hub readers may not be familiar: Nelson Cruikshank. Nelson was a longtime leader in the labor movement who was instrumental in creating two of the most important programs for vulnerable older adults and people with disabilities: Social Security Disability Insurance (SSDI) and Medicare.

Born in 1902, Nelson grew up to become a Methodist minister and, later, a union organizer. After a series of jobs in the federal government – including one setting up camps for migrant farm workers, a program later made famous in John Steinbeck’s novel, The Grapes of Wrath – Nelson became director of the AFL-CIO’s Department of Social Security. It was there that he worked to forge a political coalition that would go on to help win passage of SSDI legislation in 1956. Nelson then turned his attention to health care. Inspired by the effectiveness of community health clinics in the migrant camps he had established decades earlier, he organized a coalition of health care and senior organizations to push for a medical assistance program for older adults. This coalition took on the powerful American Medical Association, which opposed national health insurance. These efforts culminated in the passage of Medicare in 1965, signed into law by President Lyndon Johnson.

Nelson retired from the AFL-CIO soon after the passage of this landmark law, but continued to work on behalf of older Americans and people with disabilities for the next two decades. He served as president of the National Council of Senior Citizens – now known as the Alliance for Retired Americans – an organization formed out of the coalition he had created to urge the passage of Medicare. In 1977, President Carter appointed him as his chief advisor on the aged. In this role, he led successful efforts to preserve Social Security benefits.

I first learned about Nelson from his daughter, Alice Hoffman, who I encountered while making ACA defense phone calls. This serendipitous conversation also led me to learn that Alice is an impressive advocate in her own right. At 86, she lives in Pennsylvania and takes an active role in defending the ACA, including her efforts as a member of the Pennsylvania Health Access Network. Alice recounted a story of a visit to her retirement community from her congressman, who told the audience of older adults that while Medicare and Medicaid were going to undergo drastic changes, they wouldn’t have to worry since it “won’t affect you.” No shrinking violet, Alice immediately stood up and challenged the representative’s assumption that older adults don’t care about the next generation. Her comment was met by loud applause and cheers from her fellow audience members. More recently, Alice has become very involved in a coalition working to advocate for a single-payer health system, carrying forward her father’s vision of achieving high-quality, affordable health care for all.

It was an honor to meet Alice, learn about her father and know that his legacy of advocacy has been passed on to the next generation. She truly embodies the spirit of this year’s Older Americans Month theme, powerfully demonstrating what it can mean to “Age Out Loud.”

As Republicans struggle to come to agreement on how far to go with ACA repeal and what to put in its place, they are confronted with three interlocking math problems: first, how to make their budget numbers add up; second, how to put together a proposal that can command a majority in both the House and the Senate; and third, how to avoid running afoul of public opinion.

Where to Start?

Let's start with the budget problem. The budget reconciliation instruction only requires Congress to save $2 billion over 10 years, which is barely even rounding error in the context of overall federal health spending. It should be easy, right? But the complications begin immediately with the Republican commitment to repeal the taxes that helped pay for the expanded benefits in the ACA.

How to plug that hole? In the good old days of "repeal and delay" (about a month ago), you simply wiped out all of the ACA spending – including both the tax credits for marketplace coverage and all of the Medicaid expansion funds – and made some vague promises about fixing it later, someday, maybe (not!). But “repeal and delay” ran aground on the other two problems – public opinion, which is strongly against it (only 18 percent support this course), and that constituents have not been shy about making their objections known to their members of Congress.

As a result, there aren't enough votes to pass repeal and delay, so GOP leadership is in need of some kind of replacement plan. That replacement plan has to make good on Republican commitments to preserve access to coverage for people with pre-existing conditions and also has to avoid yanking Medicaid coverage (and funding) away from states. But preserving funding for the Medicaid expansion (even if the federal matching rate phases down over time) and creating a substitute for the ACA tax credits, even at reduced levels, eats up some of your savings, so you are still left with a budget hole.

How big a hole depends on how much of the expansion funding is preserved and how adequate are the new tax credits. The greater the funding preserved, the bigger the budget hole. But proposals to shrink the funding have fueled opposition in states that have benefited from the Medicaid expansion, including 16 states with Republican governors. It would also cause the number of uninsured to spike and do little to allay the public's fear that people with pre-existing conditions will again be locked out of the insurance market. 

A notable feature of the recently leaked draft House repeal-and-replace plan is that it tries to address these problems by providing more funding for the Medicaid expansion and for subsidizing private insurance than did previous proposals, such as the one authored by now-HHS Secretary Tom Price. But because at least a portion of the ACA funding is preserved, a sizable budget hole remains, although we don't know how big because no CBO score has yet been made available.

Fixing a Hole?

How is this hole to be plugged? Again according to the leaked plan, there are two additional revenue sources. One, involves cuts to the core Medicaid program; the other involves changes to the tax exclusion for employer-sponsored insurance, in the sphere of the ACA's "Cadillac tax" that places an excise tax on the most expensive health plans. But both of these revenue sources immediately run into trouble with respect to math problems two and three, above. The "Cadillac tax" is wildly unpopular with both the public and in Congress, across party lines. It is not at all clear that a majority of members will repeal the Cadillac tax only to turn around and support replacing it with something that essentially does the same thing.

On the Medicaid front, the House proposal is to continue to provide states with enhanced matching funds through 2019, but only for those beneficiaries who are currently enrolled. New enrollees would receive only the regular match rate. Starting in 2020, states would receive a capped amount for each beneficiary. The proposal calls for this capped payment to grow at the rate of medical CPI plus one percentage point. It's not clear that this adjustment factor saves a lot of money. If not, it then doesn't do much to fill the budget hole (running into math problem one).

The House Medicaid proposal differs significantly from another leaked proposal, this one developed by a number of Republican governors. In particular, the governors do not want to be forced to assume increased risk for the cost of care for beneficiaries who are jointly eligible for Medicare and Medicaid. (The "dual eligibles" account for over one-third of all Medicaid spending.) At the same time, at least some Republican governors seem perfectly comfortable with substantial Medicaid funding cuts as long as they have increased freedom to cut people off of Medicaid and reduce benefits for those who remain. Of course, this would just shift costs onto providers and beneficiaries. In essence, perhaps in an effort to keep senior citizens, people with disabilities and the providers who serve them on the sidelines, the governors' plan boils down to massive eligibility and benefit cuts for non-disabled adults and children.

Especially if the votes aren't there for tackling the tax-exclusion, then the Medicaid cuts would have to be deeper – much deeper – than what is laid out in either of the leaked draft proposals.  And benefits would likely be even skimpier both for Medicaid beneficiaries and in the private market. An analysis of the replacement plan based on documents released by Speaker Ryan suggests that millions would lose coverage. Such draconian cuts in health coverage would spark even more public outcry and could erode support in both the House and Senate, even though one House leader called a decline in coverage "a good thing" (again, see math problems two and three, above).

All in all, once the "original sin" of repealing the ACA taxes is committed, solving all three "math problems" – i.e., finding a way to make the budget numbers work while keeping a majority of support lined up in both the House and the Senate and not enraging the voters – adds up to a monstrous headache for Speaker Ryan and Leader McConnell. (Sad!)  Perhaps that's why former House Speaker Boehner predicts that the Republican effort to repeal most of the ACA will ultimately fail.

Let's hope he is right.

This is the second blog in a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.

In 2015, Belhaven, North Carolina Mayor Adam O’Neal and supporters from 11 other states set out on foot for their second 300-plus mile trek from his rural town to our nation’s capital to draw attention to an important issue: rural communities in danger of their hospitals closing.

The walk idea was sparked when O’Neal’s local hospital, Vidant Pungo, closed its doors in July 2014. For many in that small town, not only were those hospital jobs lost, but the nearest hospital is now 30 miles away. Sadly, this is a scenario being replicated all across America. A major source of rural hospitals’ financial stress can be traced to their state decisions to turn down federal funding to cover more people through Medicaid. With some Republicans in Congress and the incoming Trump Administration bent on repealing the Affordable Care Act (ACA) with no plan to replace it, we seem to be moving further from finding a solution to this crisis.

For the 50 million Americans living in rural parts of the country, accessing health care has often meant facing a variety of barriers: difficulty making an appointment with a provider or specialist, traveling long distances to the nearest hospital, and a high rate of local hospitals closing their doors. People living in rural areas will have even more to lose if the incoming administration dismantles the gains we've made under the ACA.

Figure A. Rural Counties Across the U.S.

In the past six years, while millions of Americans have benefited from the ACA, Americans living in rural areas have made more progress under the ACA than the general population. People living in rural communities saw a 7.2 percentage point increase in coverage from 2013 to 2015, compared with a 6.3 percentage point increase for urban individuals. Of the nearly 2 million rural customers who bought health coverage through the ACA Marketplace in 2016, about 9 out of  10 rely on tax credits to make their coverage affordable. Also, because of the ACA, the share of rural Americans who cannot afford necessary care decreased by six percentage points. In real terms this means that families are able to have coverage regardless of their health status and are able to take advantage of financial assistance to make it possible.

But now these much-needed health care gains for rural communities are under threat. Congressional leaders and the incoming administration have indicated the first item on their agenda is repeal of the ACA without a replacement plan (including a repeal of Medicaid expansion). Rural Americans’ health coverage and livelihoods could be hit especially hard.

In addition to historical barriers to care, rural America’s struggles with health care are rooted in policy decisions that have left them worse off. For example, rural individuals are concentrated in states that have resisted reforms available to them under the ACA, like Medicaid expansion. These state decisions have had significant implications: more than a million rural individuals fall into the Medicaid coverage gap and many hospitals in rural areas are unable to draw in the benefits of a more insured patient mix. This is a large reason why more than 70 rural hospitals – most located in non-expansion states – have shut down since 2010. Many more hospitals are at-risk of closing because of financial pressure, in which Medicaid expansion would provide a lifeline. Hospitals are important employers and contributors to the local economy, so these hospital closures are happening to rural communities that can least afford to lose these economic benefits. Our rural communities know all too well the struggles of keeping their communities healthy and safe. Any reforms undertaken on a large national scale should improve health care, not put it in a state of uncertainty (Figure B). 

Figure B. Why the ACA is A Critical Lifeline for Rural Communities

Repealing the ACA without an adequate replacement would shut off any hope of saving these vulnerable communities from additional hospital closures. ACA repeal would also deny a pathway for individuals to gain affordable coverage and endanger gains made in rural communities in states that have embraced the health law.

One state with a lot at stake is Kentucky, which closed the coverage gap and set up its own state-based exchange under the ACA. Because of these decisions, the state’s uninsured rate dropped from 20 percent in 2013 to only 7.5 percent in 2015 – one of the biggest successes in the nation. Rural areas of Kentucky, which have been hard hit by poverty and poor health, disproportionately benefit from these gains in coverage. Ending the health law could be detrimental to in places with a high share of rural communities like Kentucky and Louisiana as well – which also closed their coverage gap in 2016 – where many have been able to obtain health insurance for the first time and use important preventive services that are shown to improve health and cut health costs over the long-term.

Communities are only as healthy as the people that comprise them. When people are healthy, they are able to raise thriving families and contribute to their local economies. This could not be truer in rural America, where the communities here would be in some of the greatest danger if the ACA is repealed without an appropriate replacement plan that protects and expands on the coverage gains of the last six years. 

It is often said that the first casualty of war is the truth. In the coming war on health security for the American people, one question is whether Donald Trump was sincere when he said he would not cut Medicare, a claim he made repeatedly throughout the campaign. Unfortunately, his selection of Tom Price as head of HHS raises a bright red flag as to whether Medicare is truly safe. 

Price is on record not only supporting Medicare vouchers but also for allowing doctors to balance bill Medicare patients - as if people in this country didn't already have big enough problems with out-of-pocket medical bills. Based on his history, it is hard not to believe that older Americans and people with disabilities will be right up there with low-income people and people with pre-existing conditions at the head of the line to receive a cut in their health care benefits from the president and congressional Republicans.

And while we’re at it, I wouldn’t take too much comfort from stories suggesting that Senate Republicans are cool to a Medicare voucher or premiums support plan (there is no effective difference between the two, it is just a matter of whether the fixed dollar subsidy goes to the beneficiary or directly to the insurer). It's the timing of the attack, not its substance that seems to concern them most.

Meanwhile, at least some Congressional Republicans are realizing that calling for a repeal that has no chance of actually happening is a much easier exercise than actually crafting a workable alternative. Perhaps it has something to do with the fact that - despite continued division over ACA - the public is deeply skeptical of any moves to repeal it without having some clarity on the alternative. Only about one in four voters support ACA repeal, fewer than the 30 percent who want to expand the law. Roughly equal numbers support implementing the law as is and scaling it back. Even those who favor repeal want to see the alternative first.

Voters are right to be concerned. The lengthy time gap that Republican leaders are envisioning between repeal and replace would be a "slow motion disaster" for health insurance. Moreover, deep divisions over what direction to move in underscore the possibility that the party could be unable to come to any agreement on a new plan (just as they haven't for the past six years). The Senate Republican Policy Committee unveiled their plan to begin repealing what they call "the most harmful provisions of the ACA." Apparently tax credits and Medicaid expansion that make health insurance affordable for 22 million people qualify as "harmful." That’s probably a surprise to the people who are getting those benefits.

In the next few weeks, we expect the Centers for Medicare and Medicaid Services (CMS) to release a proposed rule detailing their proposal for how physicians will be paid under the Medicare program. The new rules, authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will change how Medicare will pay physicians (and certain other providers) starting in 2019.

The current system for physician payment works in a relatively straightforward manner. A physician provides a service (such as an office visit) to a Medicare beneficiary, sends a bill to Medicare, and Medicare pays the physician the defined rate for that service (“fee for service”).

Under the new system, when a physician provides a service to a Medicare beneficiary, Medicare’s payment to the physician will depend on a number of additional factors, such as whether the physician meets certain quality benchmarks or participates in an “Alternative Payment Model,” such as an accountable care organization (ACO).

MACRA creates two payment pathways. The first is the Alternative Payment Model (APM) pathway. A physician can qualify for this pathway by having a certain percentage of payments under alternative payment model arrangements, to be defined by CMS. These alternative payment arrangements require physicians to take on some level of risk for the financial and quality outcomes of their patients’ care. The second is the Merit-based Incentive Payment System (MIPS) pathway, which retains more of the existing fee-for-service structure, but adds in quality incentives and penalties. The two different payment pathways are calibrated in order to push physicians into the APM pathway.

From the consumer perspective, MACRA matters because, if implemented carefully, it can promote more flexible care that is tailored to the needs of patients. And, because Medicare is the 800-pound gorilla in the health care system, MACRA’s payment incentives will likely drive physician and health care organization behavior nationwide. Specifically, by defining which APMs “count” toward the APM pathway participation requirements, MACRA will strongly influence the kinds of payment and care delivery models that are created in this country and define a set of quality measures that physicians need to meet.

While MACRA can drive the move toward “value-based payments,” the push for innovation must be carefully balanced against the need to smooth implementation. From a consumer perspective, the push toward risk-based payments must be balanced with strong consumer protections, and structures for meaningful consumer engagement in the design, implementation and oversight of these payment models. It is also important that the quality measures selected for both the MIPS and APM pathways reflect patient-centered priorities, such as patient experience and patient reported outcomes.

We have been keeping a close eye on MACRA developments. In December of 2015, CMS released a draft of its plan for developing the measures to be used under MIPS. We submitted comments, emphasizing the importance of measures that reflect patient experience and the importance of payment models that make sure providers who care for patients with complex social and medical needs will not be disadvantaged. We will be taking a close look at the forthcoming proposed rule which will be followed by a public comment period, to make sure that it is as consumer-protective as possible (our previous comments on MACRA can be found here). We expect a final rule in November of this year. We encourage Hub readers to keep an eye out for MACRA-related developments, to understand the impacts of this sweeping new program.



This guest blog by Marcus Escobedo, Senior Program Officer at The John A. Hartford Foundation, was originally published February 18 in the foundation’s Health AGEnda blog.

To fulfill our mission of improving the care of older adults, it is critical to know what is working—and what is not—when it comes to health care for the nation’s growing number of older people. That is why The John A. Hartford Foundation supported a new report from the Dartmouth Atlas Project titled Our Parents, Ourselves: Health Care for an Aging Population.

“This report is really about success,” says Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation. “Life expectancy has almost doubled since the 1900s, from 40 years to 80 years today. The number of adults over age 65 also is projected to almost double in the coming decades, from 43.1 million in 2012 to 83.7 million by 2050. This is truly remarkable and something to celebrate. However, we now need to achieve the same level of success in meeting the care needs of this growing aging population.”

The Dartmouth Atlas report should help. In fact it should be required reading for health system leaders, advocates, and policymakers. It can help them understand the composition of Medicare beneficiaries in their communities, those beneficiaries’ experience of care, and whether they are receiving evidence-based health care along a number of dimensions directly meaningful to older adults and their families. For example, the report looks at the number of unique clinicians that patients see on average, as well as end-of-life treatments, such as late hospice referral and the number of days spent in intensive care.

Based on 2012 Medicare data, this report card is helpful because it breaks down by geographic region where the United States is making progress in patient-centered care for older adults and where improvements are needed. It also breaks new ground, sharing data that has never been public before, including:

  • Older adults with two or more chronic conditions spent 33 days—or just over one month of the year—in contact with the health care system (in the hospital, at a doctor’s office, or at a lab visit).
  • The average Medicare beneficiary was in contact with the health care system on 17 days. Looking at the data by geographic region, the range spanned from 10.2 days in Lebanon, N.H., to 24.9 days in East Long Island, N.Y.
  • 18.4 percent of older adults filled at least one prescription for medication identified as high-risk by the National Committee for Quality Assurance. Again, the rates varied greatly depending on geographic region, from 9.8 percent in Rochester, Minn., to 29.1 percent in Monroe, La. Progress in this area is being made, as the percentage of Medicare beneficiaries who filled at least one high-risk medication prescription dropped 43 percent from 2006. But more work is needed to eliminate this dangerous practice.
  • Preventable hospital readmissions have declined 23 percent, from 5.5 percent of Medicare beneficiaries in 2003 to 4.2 percent in 2012. Again, since these are by definition “preventable” readmissions, we must keep working to lower the rate to as close to zero as possible.

The John A. Hartford Foundation is very proud to support the work of the Dartmouth Atlas Project, and our commitment to patient-centered and patient-directed care for all older adults is only strengthened after reading about the large variations in quality of care that currently exist depending on where people live. This report describes both the real and potential care needs that we must address. The discussion we need to have in light of this eye-opening report must center on the kind of care that older adults want, need, and how they want that care delivered.

The John A. Hartford Foundation was one of the earliest supporters of Dartmouth’s work looking at regional variation in the 1980s. The resulting Dartmouth Atlas Project underscores that big data can make a big difference in our ability to improve the care of older adults. The Atlas provides a huge service to everyone who does research, makes policy, or cares about the health of older people. It is a great tool that we know our grantees and the field will find helpful.

Download and share Our Parents, Ourselves: Health Care for an Aging Population so that it will be referenced and used by hospitals, community providers, and others in their field to make important and needed changes in the care we deliver to older people in this country.

For more information, including links to The John A. Hartford Foundation’s full press release and key data tables, visit the foundation’s Our Parents, Ourselves page.

Marcus Escobedo
Senior Program Officer, The John A. Hartford Foundation

A half century seems like a good time to celebrate and take stock of Medicare and Medicaid—our two bedrock programs providing health security to millions of older adults, people with disabilities, children and low-income families. Not only did these programs open the doors to health and economic security to their beneficiaries, they have played an essential role in breaking down the (legal) segregation in our health care system and supporting major technological advances in health care. (An under-appreciated bit of Medicare history: prior to passage hospital wards were segregated, but hospitals had to desegregate in order to receive Medicare funds

As I reflected on this anniversary, what came to mind was this quote that is often attributed to Thomas Jefferson, but appears to actually have been said by the abolitionist Wendell Phillips: "Eternal vigilance is the price of liberty" and, he went on to add "power is ever stealing from the many to the few."

No victory is ever permanent. Once it has been won it must be defended, essentially forever. While ACA proponents aspire for the law to achieve the popular status of Medicare and Medicaid, just last week a major political figure mused out loud about the need to end Medicare (at least as we know it). Although both programs were passed with bipartisan support, there remains a segment on the far right that has never accepted them. If you are looking for speculation as to why you can look here and here.

Despite, and in part because of, their great achievements, the programs face serious threats and challenges that must be overcome if they are going to survive for another 50 years.

Challenges for Medicare

Persistent efforts to change the program from defined benefit to defined contribution are the biggest threat to the future of Medicare. That effort has two parts, one that may not undermine the program, but is well underway, and another that remains a right wing talking point (for now).

The first part of the original, and still active, plan to get Medicare to "whither on the vine" was to move people away from "traditional Medicare" and into a more privatized system. Medicare Advantage has been the vehicle for accomplishing this. Medicare Advantage plans’ deliberately higher payment rates have helped it become a firmly established program, with nearly one third of Medicare beneficiaries enrolled. While the ACA has dialed back those overpayments, for many beneficiaries, Medicare Advantage is simply the most cost-effective option.

The real prize for those who want to take down the program, is moving from defined benefit to defined contribution. Under a defined contribution scheme, instead of being guaranteed a set of benefits for no more than a certain cost, the federal government would make capped per-enrollee payments that could be used to purchase private insurance. Most analysts anticipate that the size of the federal payments would not keep up with the rising cost of health care, shifting more and more cost onto beneficiaries over time (indeed, this is a feature not a bug--it's how defined contribution saves money).

While opponents are active in attempts to destabilize Medicare, there is a competing vision for the future of the program. The goal is to progressively improve the quality and efficiency of the program, particularly for the sickest beneficiaries who use most of the program's dollars. Many ACA provisions—accountable care organizations, bundled payments, etc.are an effort to implement that vision and improve the long term affordability of the program from a budget perspective without shifting costs onto beneficiaries. These efforts, while in the early stages, offer the promise of both better care and lower cost.

Challenges for Medicaid

Medicaid is the program that everyone loves to hate but hates to cut. Federal budget hawks worry about the program’s cost and state officials struggle to fund the program while still paying for other state services. Providers regularly decry the low payment rates. But when it comes down to it, cutting Medicaid is generally an unattractive option for states facing a budget crunch. Since most of the savings from any cut go back to the federal government, Medicaid cuts represent a high pain, low gain approach to states managing budget challenges. And while providers grumble (and sometimes sue) over Medicaid rates, they are far better than nothing at all.

Again, there is a draconian vision for the future of Medicaida federal block grant to states that doesn't keep pace with rising health care costs. Such a block grant would come with few strings attached and leave beneficiaries increasingly unable to afford or access medical care.

While the block grant debate is perennial in Congress, less extreme, but more pressing challenges loom largely from the fallout from the Supreme Court decision that created the coverage gap. As states debate closing the gap, two main threats have emergedincreased cost sharing and restrictive eligibility rules.

The effects of cost-sharing on low-income people are clear and well known. Premiums will discourage enrollment and co-payment will be a deterrent to seeking necessary medical care. Notwithstanding these negative effects, some degree of cost-sharing is often supported even by proponents of closing the coverage gap. The principle of universal contribution has to be balanced against the potential for economic hardship--a point that too often gets lost in the policy debate where cost sharing is often wielded as a strategy to suppress enrollment and use.

The other threat, which has made no headway thus far under with federal officials, is to return Medicaid to its welfare roots (albeit with a twist). In 1996, welfare reform severed the link between cash assistance and health care but some state officials are trying to shoehorn Medicaid back into a welfare program (think work requirements) instead of allowing it to serve as the foundation of our nation's multi-layered coverage strategy.

If block grants, skimpy coverage, work requirements and financial barriers are one dystopian vision for the future of Medicaid, what about the other side? Is there a more positive vision?

Indeed there is. Like Medicare, there are efforts across the country to make Medicaid work better. Recent federal regulations are an effort to improve the quality of care for beneficiaries. As with Medicare, states are looking at ways to change how care is delivered and paid for to better and more efficiently provide care to high-need, high cost beneficiaries. The ACA has also created tools that can be used for more sweeping changes. Examples include the global budgeting waiver in Maryland and the now stalled single payer effort in Vermont. 

Can the more optimistic vision of the future of Medicaid and Medicare prevail?

It will not be easy. One challenge to the financial sustainability of both programs is the growing cost of prescription drugs (a topic for another day). However both Medicaid and Medicare remain popular at their 50th anniversary and are strongly supported by organized consumers and providers. If we remain vigilant, Medicare and Medicaid can not only survive for 50 years they can thrive and continue to provide people with access to care and financial protection over the long-term.

Lyndon B. Johnson signing the Medicare bill. Fifty years ago today, President Lyndon B. Johnson signed into law the landmark amendments to the Social Security Act that created the Medicare and Medicaid programs. In his comments at the signing, President Johnson made explicit the connection between the right to health care, and the financial security of older Americans and families of all ages. In the half century since, these two life-changing programs have indeed provided that security to tens of millions of adults over age 65, people with disabilities, children and families, pregnant women, and low-income Americans.

At the time of enactment, roughly half of all older adults in the United States had no health insurance. Today, Medicare and Medicaid cover nearly 1 out of every 3 Americans – more than 100 million people. But there are still millions more without coverage of any kind, or with coverage, but inadequate access to care and services they vitally need.

While a pause for celebration is in order today, complacency is not.

The United States continues to spend almost twice as much per capita on health care as any other western democracy, with far less “bang for our buck,” in terms of health status and outcomes to show for it. Significant health disparities and unequal access to quality care continue to be hallmarks of our health system. These issues pose a threat to the sustainability of Medicare and Medicaid, as well as new programs established under the Affordable Care Act.

The ACA was carefully crafted to build upon – and improve – the solid footings Medicaid and Medicare provide for the health care of vulnerable populations, even as it created a new pathway to coverage for millions more through the insurance Marketplaces.

Beyond establishing the Marketplaces, the ACA has many other provisions that are already changing the health care landscape in dramatic ways:

  • First and foremost, the provision insuring more people through Medcaid was envisioned to take effect in every state, to dovetail with the eligibility guidelines of the Marketplaces. Advocates are working tirelessly in those states which have yet to close the coverage gap to make that promise a reality in all 50 states.
  • The Medicare-Medicaid Coordination Office, created under the ACA, is overseeing financial alignment demonstration projects in a dozen states to address the very real difficulties that people eligible for both Medicare and Medicaid confront daily due to the different rules and benefit guidelines, and often fragmented and uncoordinated care they produce. Our Voices for Better Health Project is working with state partners and geriatric provider experts to help implement these demonstrations to provide the best integration and coordination of care possible, while protecting consumers and helping them make their voices heard in the process.
  • The Center for Medicare and Medicaid Innovation (“The Innovation Center”) is another creation of the ACA. This center is working to seek out, evaluate and pilot new payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through improvement of the health care system.

There is much more advocacy needed to expand the reach, quality, equity and cost effectiveness of both Medicare and Medicaid in the decades ahead. Community Catalyst and our state partners are committed to working together to transform our health care system into one that operates effectively and efficiently to ensure all people get the care they need and that invests in keeping them healthy. 


For today, please join us in wishing a Happy 50th Anniversary to Medicare and Medicaid!

Fifty years ago this week Medicaid and Medicare were signed into law. These two programs provide children, seniors, people living with disabilities and working families with access to the health care they need. To celebrate 50 years of these two programs, each day this week one of our partners will share a story about their work to ensure more people can access Medicaid. We’ll also be reflecting on the two programs and what’s ahead. 

Hannah is a 27-year-old member of the Confederated Salish and Kootenai Tribes in northwest Montana. She works as a massage therapist and research assistant, and is also a caregiver for her elderly grandmother and quadriplegic cousin. Two years ago, Hannah was diagnosed with Lyme disease and recently her health has declined drastically.

Right now, Hannah is uninsured. She can’t afford health insurance and doesn’t make enough to qualify for tax credits. She’s able to access basic health care through Indian Health Services (IHS), but is unable to get the specialist care she needs to manage her Lyme disease. She had to pay $900 out of pocket for lab work just to get a definitive diagnosis.

“Having expenses for medical care is really hard for my family,” Hannah said. “Medicaid would give me the chance to see a doctor where I live and  live a healthy, normal life.”

Hannah is just one of approximately 20,000 American Indians in Montana who will benefit from closing the coverage gap by expanding access to Medicaid. Montana ranks highest of any state in uninsured American Indians (40 percent) and the second lowest in number of American Indians with private insurance (28 percent). IHS faces an ongoing and severe funding shortage, with federal funding covering only 60 percent of the demand for care. Many American Indians who rely on IHS for care experience a lack of access to specialty care, like Hannah, preventative care, or early treatment for chronic disease. Medicaid plays a very important role in bridging the gap in access to care.

Current Medicaid recipients in Indian Country are able to seek care from IHS-run tribal or urban Indian clinics, as well as other non-tribal health care facilities. In addition to better health outcomes and continuity of care, Medicaid provides an influx of federal dollars that creates an economic boost to IHS and communities in Indian Country. This federal funding can increase the capacity of IHS to meet the health care needs of the community, improve their core services, and update equipment and facilities.

Services provided by IHS to American Indian Medicaid recipients are 100 percent reimbursable by the federal government, and this reimbursement rate will not change when the coverage gap closes. Not only do Medicaid recipients get better access to health care, and not only does IHS receive a much needed influx of funds, but there is no fiscal obligation to the state.

For years, Medicaid has helped to create strong and healthy individuals, families, and communities in Indian Country. As we celebrate Medicaid’s 50th anniversary, we should celebrate the positive impact Medicaid has on reservations and in urban Indian communities, and we should also remember that we have a unique opportunity to continue to improve health care and support communities in Indian Country through Medicaid expansion. For Indian Country, closing the coverage gap is one step toward eradicating generations of extreme health disparities affecting American Indians. Most of all, it is a commitment that will strengthen Montana’s families, communities, and economy.

Sarah Howell, Executive Director, Montana Women Vote

To mark Older Americans Month, the Voices for Better Health project has debuted a new video highlighting an important strategy to improve the health and well-being of vulnerable older adults. “Building Bridges to Better Health” tells the story of an innovative collaboration between consumer advocates and providers to infuse geriatrics best practices into the Demonstration Projects for people with both Medicare and Medicaid (dual eligibles).

Working nationally and with Voices for Better Health state partners, this powerful partnership draws on the expertise of leaders in the geriatrics community – physicians, gerontologists, nurses, social workers and other providers and researchers – sharing best practices to improve efficiency, quality and outcomes in the demonstration projects. This collaboration has increased the effectiveness of state advocacy efforts around these demonstrations. With people of color making up a disproportionately large percentage of the dually eligible population, we also see this work as helping to build another important bridge – to health equity for all.

While “Building Bridges” focuses on the dual demonstration projects, it affirms that breaking down silos and strengthening alliances with providers is an indispensable approach to creating a path to a people-centered health system, both for older Americans, and those of all ages.

« Show Older Posts