In the Washington Post on Monday, Louisiana Governor Bobby Jindal issued an invitation to the President to meet with Republican governors to discuss Medicaid reform:
Medicaid operates under a 1960s model of medicine, with inflexible, one-size-fits-all benefits and little consumer engagement and responsibility. Expanding the entitlement program as it stands would further cement a separate and unequal tier of health coverage. Without fundamental reform, Medicaid will continue to deliver what it has for decades: limited access, poor quality and budget deficits.
Fortunately, after nearly a half-century of running this program, states know its problems and how to address them.
A number of Republican governors have asked to meet with President Obama to discuss their solutions, but the White House has ignored these requests. The president claims that he wants to work across party lines to get things done for the American people, so perhaps he could start by meeting with Republican governors who want to solve our nation's health-care problems.
Jindal knows what he's talking about. The governor inherited a Medicaid program that cost $7 billion and covered nearly a third of the state's population (27%), but the Louisiana still ranked nearly last in major health rankings (49th), performed badly on pre-term births and infant mortality measures, with high rates of chronic disease and low use of preventive services.
In other words, like a lot of states, Louisiana was paying a lot of money for Medicaid fee-for-service care and not getting a lot of value for it. In January 2008, Jindal launched a Medicaid Reform Advisory Group to look at improving coordinated care for Medicaid enrollees. Today, the state's Medicaid program (Bayou Health) is focused on prevention, coordination, and actively managing patients with chronic diseases through patient-centered medical homes.
The state is also collecting Medicaid data on nearly 40 health measures, and can penalize private Medicaid plans that don't meet quality benchmarks. If plans meet their health benchmarks, they can also benefit from "shared savings" with the state. Medicaid enrollees can choose from a menu of private health plan offerings, but if they don't, they are auto-assigned to the best plans. Currently, Bayou Health is projected to save $135 million thanks to Governor Jindal's reforms.
You can't call these reforms liberal or conservative - they're just focused on improving value, and states from Louisiana and New York are implementing similar programs. In fact, the Obama Administration - which doesn't hesitate to vilify private insurers when it's politically convenient - is running a demonstration project whereby about 40 percent of all Medicaid/Medicare "dual eligibles" nation-wide are being moved into private managed care plans.
What Governor Jindal does want is increased flexibility to design his state's Medicaid program to meet the needs of different populations - along with the ability to vary Medicaid co-pays, benefits, and plan designs. There is no "one size fits all" Medicaid reform that will work for all populations and all 50 states, and greater state flexibility (along with better transparency for state outcomes) would just recognize this reality.
Today, the only way for states to get broad program waivers is through a lengthy 1115 waiver process; and every new administrations (Democrat or Republican) also have their own policy preferences, which limit states' ability to experiment and the federal government's ability to consistently learn from what works. Here, Jindal has a simple idea that should appeal to governors of both parties:
The process by which states negotiate for flexibility, called "waivers," is broken. Federal officials should have greater accountability for timely review of waiver applications. In particular, waiver applications based on those already approved in other states should be fast-tracked. HHS should allow states to opt in to a more flexible long-term-funding arrangement, allowing them to design programs that best meet residents' needs, rather than requiring the same package of services for every individual. At the same time, federal and state officials could agree to greater accountability for improvements in health outcomes, not just processes.
Jindal's proposal would go a long way to giving Republican governor's what they want (flexibility) while assuring provider and Medicaid advocacy groups that states will still be held responsible for improving outcomes for Medicaid enrollees. In other words, it's a win-win.
A broad based conversation about Medicaid reform should have happened long before Obamacare was passed, but instead the governors were largely locked out of the discussion - a big reason many governor's are balking at Obamacare's massive Medicaid expansion today.
It's not, however, too late to go back to the drawing board and fix a program that millions of Americans depend on for safety net care.
The president keeps saying that he's open to any good ideas, whether they come from Republicans or Democrats. Governor Jindal is taking him at his word.
Mr. President, are you willing to meet him halfway?