What Medicaid expansion reveals about healthcare reform

(I've been enjoying Tim's coverage of Medicaid over at Change.org's Universal Healthcare blog, and hope my fellow anti-poverty activists are checking it out.  As we turn our attention again this week to the stimulus and its impact on poverty, I'm pleased to introduce guest blogger NycWeboy taking on Medicaid and healthcare reform here at Poverty in America. - Leigh)

One of the most heartening developments in the stimulus plan that the House passed is that Medicaid funding would receive a healthy increase. The Obama folks also are adding a new wrinkle to Medicaid by covering workers who are unemployed, but do not qualify for COBRA, the program which allows employees to extend their health benefits after losing a job (even better, the Administration has added funding to subsidize the employee cost, which can be hundreds of dollars more than the deduction from an employee’s paycheck).

The question is… can Medicaid sustain these expansions – that is, can Medicaid, with more money, reach more people, and improve care? Are both expectations realistic, or even possible? And another question is… how does this affect overall plans for healthcare reform?

Medicaid, possibly the least understood of government programs, is a very weak link in the social safety net. For years it has been underfunded, and because the plan basically provides grants to states to do as they wish, there isn’t one approach to dealing with the health care needs of the poor, but 50. And in many states, where there is little money to supplement meager federal funds, many people below the poverty line are still uncovered (then there’s the resistance of many to sign up, another issue).

S-CHIP was designed to deal with some of this, by providing more opportunity – and more money – for poor children to get health coverage and care; and now S-CHIP too has received the kind of expansion and funding Democrats had wanted last year.

The last question I posed, over how this expansion will affect overall plans for reform, reveals some of the dilemma of the issue of Medicaid sustainability. A lot of discussions of “the uninsured” that drive our discussion of the healthcare crisis can leave the wrong impression: that the poorest among us are the uninsured, when they are not, necessarily. Many uninsured are in fact workers whose employers don’t provide coverage, or make it cost prohibitive. That includes a lot of small businesses, which have been priced out of the market. But many poorer people have coverage – including elderly people covered by Medicare as well as Medicaid, Veterans in the VA system, as well as people covered by Medicaid. (And as a side note… this is the real challenge of an employment-based healthcare system.)

Though it may seem like one problem, the health care crisis is actually many problems, with different constituencies. And for the poorest communities, the questions center less around insurance, and more around access to care, and the quality of that care. This is where discussions of moving from care centered at hospitals (where a number of states and municipalities struggle with enormous cost outlays) to more clinic based care may make sense: it can reach more people and deal more effectively with common needs for preventive care.

The challenge, in the short term, will be to see if the expanded funding of Medicaid – and the subsidizing of COBRA – are enough to tide us through this crisis. I suspect we will discover, soon, that it’s not enough… and at the same time, face an enormous challenge with Medicare as well. And it’s why, though others are hopeful, I think the real progress in reforming healthcare policy and economics will be in adjusting what we have, not in the brave new plans for things like universal coverage. Whether progressive health advocates can accept that… is another question.