The Health 202: Expanding Medicaid instead of Medicare would offer more generous benefits

It’s an idea moderate Democrats are wary of, for a host of reasons.

“I’ve talked to a lot of people that support Medicare-for-all,” freshman Rep. Donna Shalala (D-Fla.), who served as Health and Human Services secretary under President Bill Clinton, told me. “I said I wanted to do Medicaid-for-all. That’s a better program.”

As we’ve noted before, Democrats advocating for Medicare-for-all face challenging questions about exactly how they’d fold more people into the program, how it would be paid for and what benefits would be covered. If the goal is more generous benefits, Medicaid could be a more obvious model than Medicare, experts say.

There are several categories of medical benefits covered only minimally by Medicare or not at all, including long-term care, mental-health services and most dental care. Enrollees in Medicaid, by contrast, can access a pretty comprehensive array of inpatient and outpatient services. Medicaid plans cover not only all 10 of the health benefits considered “essential” under the Affordable Care Act but also nursing home care and long-term care services.

“I think a big challenge is people don’t really have a concept of how little Medicare offers,” said Matt Salo, executive director of the National Association of Medicaid Directors. “Medicare has made a huge difference in the lives of many people over the years, but it falls short in a lot of areas.”

As his colleagues have rolled out scores of different Medicare-for-all-style bills, Sen. Brian Schatz (D-Hawaii) has proposed the “State Public Option Act,” which would allow people to use Obamacare subsidies to buy a Medicaid-type plan offered in the individual marketplaces.

Of course, this is essentially the same idea as offering a government “public option” plan on the marketplaces — an idea Democrats tried to advance as part of the ACA but eventually abandoned after strong opposition from Republicans.

And there’s another potential obstacle. The health-care industry, already up in arms over Medicare-for-all proposals, probably would hate the idea of Medicaid-for-all even more because the program reimburses health-care providers at even lower rates than for Medicare services.

Medicaid has also been the target of criticism and targeted changes from officials because it benefits those on the lower end of the income scale, offering services for Americans earning only up to 138 percent of the federal poverty level (that threshold is lower in states that haven’t expanded Medicaid under the ACA). Shalala made this observation, too: Fewer Capitol Hill staffers specialize in Medicaid policy compared to Medicare policy, since Medicaid is run by the states.

There are “just a handful of experts on Medicaid care in Congress, and most of them have retired,” Shalala said.

Yet there are some reasons to think expanding Medicaid could stand a better chance of gaining wider acceptance than growing Medicare, as my colleague Colby Itkowitz explained here. Medicaid is a program run by states — something Republicans favor — plus a number of GOP governors have embraced Medicaid expansion under the ACA.

Heather Howard, a lecturer at Princeton University who also helps states with their health-care systems, told Colby that 14 states across the country have made moves to at least weigh the benefits and challenges of making Medicaid widely available to higher-income earners.

“Why Medicaid?” Schatz wrote in a USA Today piece touting his bill. “Frankly, this program — already serving 69 million people — is underrated. It has a large provider network and the same ratings as private insurance but at a much lower cost to the government … Medicaid also gives states the flexibility to adapt services and models of care based on their individual needs.”

AHH: President Trump has nominated his former doctor Rear Adm. Ronny L. Jackson to be promoted to two-star admiral and to be his chief medical adviser.

The president previously nominated Jackson to lead Veterans Affairs, but the doctor withdrew his nomination over allegations of mismanagement and misconduct, claims still under investigation by the Pentagon, our Post colleagues Dan Lamothe and Josh Dawsey report.

“A Navy spokeswoman, Lt. Christina Sears, said Jackson is still assigned to the White House,” they write. “The Navy originally submitted Jackson’s name for promotion last year before Trump nominated him to be VA secretary, and the White House resubmitted it, she said.”

They also report Trump still likes Jackson and believes he has been unfairly treated, according to a White House official.

Because an investigation of Jackson is ongoing, it’s not clear whether the Senate Armed Services Committee will move on his new promotion nomination.

Following the president’s nomination of Jackson to head VA last year, Sen. Jon Tester (D-Mont.), the ranking member of the Veterans‘ Affairs Committee, released a two-page memo of allegations against Jackson, claiming he drank on the job, freely handed out medication, and created a hostile workplace. The White House disputed the most serious of the claims, our colleagues report.

OOF: In an effort to increase sales and push higher dosages of the painkiller OxyContin, Massachusetts Attorney General Maura Healey alleges members of the Sackler family that owns Purdue Pharma engaged in acts of deception and misconduct, our Post colleagues Katie Zezima and Lenny Bernstein report.

“In parts of the lawsuit, Healey paints a portrait of insatiable greed and disregard for the suffering that the company’s main product had caused,” they write.

Emails released as part of Massachusetts’ lawsuit against the drugmaker reveal how the family pushed the products. In one email, former Purdue president Richard Sackler “personally directed sales representatives to push doctors to prescribe extremely high doses of opioids,” our colleagues report, even as Healey claims the family knew such a move would put patients at risk.

Purdue spokesman Robert Josephson criticized the Massachusetts lawsuit, calling it “part of a continuing effort to single out Purdue” for the opioid crisis, calling the idea that Purdue had only tried to push high doses of OxyContin a “fictional narrative.”

OUCH: The controversy surrounding a failed measure in Virginia that sought to loosen restrictions on late-term abortions has reawakened a fierce debate, and partly disrupted plans by abortion-rights advocates to push initiatives and make it a defining issue heading into the 2020 elections, our Post colleagues Annie Linskey and Ariana Eunjung Cha report.

Abortion-rights supporters have made recent moves to push for state-based laws protecting access to abortion and expanding access to birth control and reproductive care. The intensified efforts are a response to the addition of conservative Brett M. Kavanaugh to the Supreme Court, prompting concerns the new conservative majority would reverse Roe v. Wade. “In New York, where Democrats won full control of the state government in November, the first measure of 2019 expanding abortion rights was enacted. Other efforts are underway in Rhode Island and New Mexico,” Annie and Ariana write.

But when Virginia Gov. Ralph Northam (D) weighed in on the controversial Virginia measure, he turned the focus from the protection of abortion rights in general to the debate over late-term abortion. Annie and Ariana report that “while abortion opponents routinely try to turn the conversation to late abortions, abortion rights advocates often keep their focus on early, more accepted procedures. The debate about the new bills sought in multiple states proceeded along those lines, until the explosion of attention to Northam’s comments."

“This is part of an organized attempt to create fear in other places and chill the effects of passing legislation,” Laura McQuade, the president and CEO of Planned Parenthood New York City, told our colleagues. “It is sexy for the right. They are trying to shut down other laws.”

— Meanwhile, Northam faces calls for his resignation over a racist photo in his 1984 medical school yearbook. The tip to the reporter who exposed the photo on Northam's yearbook page appears to have come from a medical school classmate or classmates of the governor’s who were concerned following the abortion controversy in the state last week, our Post colleague Paul Farhi reports.

Two people at the website Big League Politics told Paul about the tip. “The revelations about Ralph Northam’s racist past were absolutely driven by his medical school classmate’s anger over his recent very public support for infanticide,” one of the two told our colleague.

Northam quickly apologized but at a news conference on Saturday, he reversed himself and said he was not in the photo and didn’t know how it got on his yearbook page.

Northam called a senior staff meeting on Sunday as he considered his options, including resignation, our Post colleagues Gregory S. Schneider, Laura Vozzella and Jenna Portnoy report. A larger meeting is scheduled for this morning as national Democratic leaders call on the governor to resign.

In a weekend tweet, the president tied the photo to the governor’s remarks on the state’s abortion measure.

— The Supreme Court issued a temporary stay on a restrictive Louisiana law that challengers say would leave the state with only one doctor eligible to perform abortions.

The court ruled Friday the law could not be implemented before Thursday, our Post colleague Robert Barnes reports.

“Because the filings regarding the application for a stay in this matter were not completed until earlier today and the justices need time to review these filings,” the decision by the U.S. Court of Appeals for the 5th Circuit is temporarily stayed, Justice Samuel A. Alito Jr. wrote.

The law in question requires a doctor providing abortion services to have admitting privileges at a hospital within 30 miles of the procedure. A similar law in Texas was struck down by Supreme Court in a 5-to-3 vote in 2016.

“But last fall, a panel of the U.S. Court of Appeals for the 5th Circuit in New Orleans upheld the Louisiana law in a 2-to-1 vote, finding factual distinctions between how the restriction played out in Texas and Louisiana,” Robert writes. “The full court, considered one of the most conservative of the regional appeals courts, voted not to reconsider the panel’s decision.”

— During the State of the Union address, Trump is planning to pledge to end the HIV epidemic in the country within the next decade or so, Politico’s Dan Diamond reports.

The administration’s plan includes health officials working toward reducing HIV transmissions by 2030 by concentrating efforts in communities with the most HIV infections, Dan writes. He also reports Trump’s remarks have not been finalized and the plan for Tuesday evening’s address could change.

“The State of the Union historically has been a platform for presidents to make bold public health proclamations — many of which haven't come to pass. Former President Barack Obama used his final address in January 2016 to call for an end to cancer,” Dan writes. “The strategy was heavily shaped by [CDC Director Robert Redfield], a prominent AIDS researcher who was tapped to lead the CDC last year.”

Last year, Redfield said at an agency meeting that ending the epidemic by 2025 is possible with the use of public health tools like a push for more widespread condom use, Dan writes.

— President Trump predicted Obamacare will be “terminated,” suggesting the lawsuit brought by Texas and other Republican-led states to overturn the health-care law will eventually be successful.

“I believe it’s going to be terminated, whether it be through the Texas case, which is going through the court system as a victory right now, because of, you know, the various elements of that case. You would think it would have to be terminated,” Trump said in a recent interview with the New York Times.

“But a deal will be made for good health care in this country. That’s one of the things I’ll be doing,” he added.

Democrats on the House Energy and Commerce Committee quickly criticized the president’s remarks, tweeting that Trump “openly admits” the GOP is looking to dismantle the law through the ongoing lawsuit.

Meanwhile, four states have signed on to join 16 states and the District in an effort to defend the Affordable Care Act. Colorado, Iowa, Michigan and Nevada filed a motion to intervene last Thursday, arguing that “they should be allowed to intervene in the lawsuit to protect their existing health-care infrastructure, which would be ’thrown into disarray’ if the Affordable Care Act, or ACA, was ruled unconstitutional,” the Nevada Independent’s Megan Messerly reports.

— And here are a few more good reads: 

Court dismisses Maryland lawsuit over health-care law that also challenged Matthew Whitaker’s appointment (Rachel Weiner and Amy Goldstein)

Combating the opioid crisis one doctor at a time (Carolyn Y. Johnson)

House Democrat invites Parkland shooting survivor to State of the Union address (Elise Viebeck)

Medicare for All Emerges as Early Policy Test for 2020 Democrats (New York Times)

Cory Booker’s 2020 policy agenda: ‘Baby bonds,’ criminal justice reform, action on climate change (Jeff Stein)

Buttigieg: 'Medicare for all' wouldn't end private insurance (Politico)

The facts about Congo’s frightening Ebola epidemic. (Erin Blakemore)

An American hid his HIV status to survive in Singapore. Exposed, he allegedly punished thousands living with the virus. (Isaac Stanley-Becker)

Conservatives bash FDA for ‘regulatory panic’ on e-cigarettes (Laurie McGinley)

‘It’s way too many’: As vacancies pile up in Trump administration, senators grow concerned (Juliet Eilperin, Josh Dawsey and Seung Min Kim)

Democrats Push Plan to Increase Social Security Benefits and Solvency (New York Times )

USDA’s SNAP decision means there will be a gap in food assistance program (Joe Davidson)

Want to know where most drugs cross the border? Look at the Border Patrol’s news releases. (Philip Bump)

Today

• HHS Secretary Alex Azar delivers the keynote address at the AcademyHealth National Health Policy Conference.

Coming Up

• The Senate Health, Education, Labor and Pensions Committee holds a hearing on primary care costs and outcomes on Tuesday.
• The House Energy and Commerce Health Subcommittee holds a hearing on the GOP-led lawsuit to overturn the ACA and the impact on people with pre-existing conditions on Wednesday.
• The House Energy and Commerce Health Subcommittee holds a hearing on the Trump administration’s family separation policy on Thursday.

Watch the Washington Post's first ever Super Bowl ad: 

Watch Virginia Gov. Ralph Northam’s full press conference addressing the controversy surrounding his 1984 medical school yearbook: