Curing Medicaid’s Cold: Unwinding Pandemic Expansion Before Federal Funds End

This is Hubwonk. I’m Joe Selvaggi. Welcome to Hubwonk, a podcast of Pioneer Institute, a think tank in Boston. To ensure no one would lose healthcare coverage during COVID-19, the federal government encouraged all states to rapidly expand enrollment in Medicaid, a program established in 1965 to provide healthcare coverage for the poor, but which would now exclude no one. This federal mandate to enroll all applicants has, in the three years of the emergency, seen Medicaid membership grow to 90 million people, 15 to 20 million of which do not fit the standard eligibility criteria for the program.

Now that the Biden administration has declared an end to the emergency, states, including Massachusetts, must quickly scrutinize and remove ineligible Medicaid enrollees before the loss of federal support, less the enormous cost of the expanded program, crowd out other budget priorities, and jeopardize the healthcare benefits of eligible Medicaid patients. How can states understand who joined Medicaid during the pandemic? What would the loss of Medicaid mean for them? And what must be done to protect those eligible Medicaid recipients from being erroneously excluded from the program?

My guest today is Dr. Brian Blase, founder and president of Paragon Health Institute, a healthcare policy think tank. Dr. Blaze has written extensively about the effects of COVID-19 on programs such as Medicaid, and the need to unwind coverage expansion in a way that protects states budgets and better serves those for whom the programs were intended. Dr. Blase will share with us the history of Medicaid, the degree to which enrollment in the program ballooned during the pandemic, and the ways in which states can rapidly reexamine eligibility in a way that protects those who need it. When I return, I’ll be joined by president of Paragon Health Institute, healthcare policy expert, Dr. Brian Blase.

Okay, we’re back. This is Hubwonk. I’m Joe Selvaggi. I’m now pleased to be joined by president of Paragon Health Institute, Dr. Brian Blase. Welcome to Hubwonk, Brian.

Brian: Hey Joe, great to be here.

Joe: All right, now we’re going to be talking about Medicaid here, its purpose, its size, its recent expansion, and ways to ensure it returns to its intended mission. But before we get into the deeply into the topic, I want you to share with our listeners something about your background. You’re the founder and president of Paragon Health Institute. Tell us a little bit about your background, how you got here and to start Paragon Health.

Brian: Sure, well, I’ve always wanted to do public policy and graduate school took some really interesting courses in health economics and learned that in the U.S. we spend so much on healthcare that doesn’t provide Americans with very good value. And then a lot of the problems emanate from sort of well-intended but misguided government programs. So, I’ve had a variety of jobs in this space. I’ve worked for committees in the House of Representatives and the Senate. I’ve worked at several think tanks that focus on free markets. And then for the first two and a half years of the Trump administration, I was in the White House at the National Economic Council. After that experience, I got an opportunity to actually start my own think tank, the Paragon Health Institute, which we launched a little more than a year and a half ago, and which is growing into the leading free-market health policy think tank in the country.

Joe: All right, well that’s great. So, your job is to make sure that money is well spent. And you’re, I guess, also seeing our songs talking about how markets can be the power of markets can be harness to make healthcare more efficient. So, let’s get into the topic at hand, but going to be talk about Medicaid, which I now know is the country’s largest welfare program by, you know, substantial margin it’s fully 10% of the federal budget, and the number one line item for every one of the 50 states. So, I don’t know if you are prepared for a history lesson but where did it begin and who, you know, I’m sure you’ll be able to answer this, who’s it designed to help?

Brian: Sure. So, Medicaid was signed into law by President Johnson in 1965. It was the same legislation that created Medicare. And at the time, Medicaid was an afterthought it actually didn’t even warrant any remarks in President Johnson’s speech where he announced the creation of Medicare. But like you said, it’s now the nation’s largest program. And because of the sort of dramatic increase during clover, about 85 million people enrolled in Medicaid.

Medicaid pays for medical expenses and long-term care expenses for certain categories of low income and release. Typically, or traditionally, that was low-income children, pregnant women, seniors and people with disabilities. The program has been expanded over time with the most dramatic expansion in Obamacare, which provided states pretty large reimbursement rate if states adopted the Medicaid expansion.

Joe: So, that’s a big number. Again, you threw out some data points. I read it’s $734 billion on Medicaid. And that’s the Department of Defense size budget. That’s enormous, right? This is 734 with a B.

Brian: Yeah. And that’s split between the federal government and states. So about two-thirds of the cost is borne by Washington. And about one-third is by borne by states.

Joe: And well, again, I’m talking to you from Massachusetts. I looked it up. We spent about $17 billion on Medicaid here, as you mentioned, about a third from the state and the taxpayers and about two-thirds from the federal government. There’s an interplay between federal and state governments. The federal government, there’s carrots and sticks. It provides incentives. What are some of those incentives? Let’s take out, let’s say, Obamacare for now or even the pandemic, which we’re going to get into. How do states and the federal government decide how much is going to be paid and where are the incentives there?

Brian: So, the federal government sets out sort of basic rules on eligibility and benefits and then states determine how much to pay providers, how much to pay managed care companies because Medicaid services are increasingly delivered through insurance companies. And whether to provide optional services like dental and vision. The big carrot is that the federal government provides an open-ended reimbursement of state Medicaid spending. The reimbursement percentage is largely a function of state per capita income. So, the theory was that poorer states have less fiscal capacity. And they would get a higher federal reimbursement than states like Massachusetts. I mean, you’re one of the wealthiest states in the country and Congress set a floor at 50%. So, when wealthy states, about 50%—well, 50% of the spending is from the state. Now Obamacare came in and created a new class of individuals with a much higher federal reimbursement percentage. So that’s actually a significant other problem with Medicaid policy—is that the federal government provides much more generous terms for the able-bodied, working age expansion population, which leads states to have an incentive to over-provide care and services for the expansion population at the expense of traditional enrollees like those low-income children and pregnant women.

Joe: So, I want to parse that a little bit more that you’re going to the area where I really know nothing about the, the expansion with Obamacare. Again, the program Medicaid was designed for again children, pregnant women, the elderly, the poor. This Obamacare expansion created an incentive to, I guess you said, over-provide, say more about that. How did Obamacare affect Medicaid?

Brian: So, the expansion, it was a key part of how the federal government intended to expand health insurance coverage, which was the goal, sort of the underlying purpose of Obamacare. And the Supreme Court, though, in the 2012 decision that upheld the constitutionality of the law, because it said the individual mandate was a tax, said that Medicaid expansion was optional, and Medicaid expansion was very divisive at the time. So, in 2014, about half of the states expanded Medicaid, and the terms were made very generous for states that extended them. So, the first three years, the federal government agreed to pay 100% of the cost of the expansion population.

Now, if you think about the incentive that that creates, states know that the federal government is paying the complete cost of the expansion. States have literally no incentive to be cost-conscious, and they have incentives to qualify as many people under the terms of the expansion as possible. So states that expanded such much higher enrollment and much higher spending than projected. Fast forward to today—about 15 of the remainder of states have adopted the expansion over time. So now it’s only about 10 states that continue to turn down the federal money and have not yet expanded their Medicaid program.

Joe: So, free, free healthcare has its appeal, and the states have moved accordingly. So, I don’t want to get too bogged down on Obamacare, because I want to bring us up to current events, which is the latest crisis, so the pandemic, the emergency associated with COVID. And it makes sense, as you say, these are well-intentioned programs whereby you put everybody at work, it’s a health-related emergency, you want to encourage people to get the care that they need, so you effectively say to states, do what you have to do, we’ll back you up 100% with money. What happened? Describe how that all went down during the pandemic. How did Medicaid get affected by the pandemic?

Brian: Sure. So, in March 2020, there was a concern that people would lose their jobs, and they’d lose their health insurance, because a lot of people get their health insurance through work, and you’d have a big surge in the number of the uninsured. So, what Congress did, it had two aims. One, it wanted to get money to states as quickly as possible, and just increasing the share that the federal government pays for states’ Medicaid programs is like a really quick way to get money to states, and then it wanted to reduce the number of people who lost their health insurance. So, Congress increased the federal reimbursement, contingent on states not removing anybody from their Medicaid program, even if they lost eligibility for the entire course of the public health emergency. And the public health emergency lasted a very long time, right, it lasted more than three years. So states—and this is a population, a low income population, like people often aren’t low income for a very long period of time. They earn more income. You know, if they’ve lost their job because of the pandemic, most people were reemployed pretty soon after. So, they got back to work. They got another offer of employer coverage. So, states haven’t done any eligibility reviews in three-plus years, which have led to estimates say between 15 to 20 million people on the Medicaid program. As of April 1, we won’t meet the eligibility requirements.

Joe: All right, so we’ve got 15 to 20 million people who because they were really the federal government said to states ‘Look, you no longer want to scrutinize applicants to see whether they’re eligible. Everybody’s on, no questions asked during the pandemic.’ Now the pandemic is past, you’ve got a massive number of new members. Does everybody agree that these this expansion needs to be unwound and what what’s going on? Essentially if taxpayers are paying 15 to 20 million people who ought to be on some other program, what’s next?

Brian: Everybody doesn’t agree. There are some folks, particularly on the Left, that sort of see Medicaid for all as the way to get universal health coverage, but Congress agrees. So late last year Congress passed legislation that allowed states to start doing redeterminations April 1, and that phases out over the course of this year the extra money that states got for the pandemic for this population. So, starting in April, there were four states that began redeterminations. About a dozen additional states started in May. Most of the states are starting that process in June or July, and, over the course of about the next 12 months, states will be reviewing eligibility for people on the Medicaid program and removing individuals that are no longer eligible.

Joe: So, I can hear the collective cry of my progressive friends listening to the show assuming that you and I are bad people, mean spirited, want to push old ladies and children into the snow when they’re sick. Your paper that I read makes a provocative claim. I want to reassure my progressive listeners that that’s not our intent or your intent at all. You make the claim, I think it’s a bold claim, that 99 percent of those who are — as we both agree — are ineligible, aren’t going to go without health insurance. They’re going to go somewhere else. Describe for our listeners what happens — let’s imagine we had a magic wand, we could identify all 15 to 20 million people who are, as you characterize, ineligible. Where would they go?

Brian: Yeah, so this is the estimates that I’m citing are from the Urban Institute, which is a, you know, organization on the left that does empirical estimates of the impact of health policies on states. So, they estimate that there’s about 18 million people that are ineligible for the program. About 10 million of those individuals will replace Medicaid with employer-sponsored insurance.

Now, the half of them are concurrently have been enrolled in employer-sponsored insurance and Medicaid, which is another problem that we should get to. Of the 18 million, 4 million people are kids that are going to replace Medicaid with the children’s health insurance program. One million are people that have are going to replace Medicaid with individual market coverage, mostly using a pretty large subsidy to buy on the exchange. Now, 3 million of the 18 million are projected to be uninsured after this. So, that’s about a sixth of the ineligible people. Now, how do you reconcile that with the 99% statistic that you said? Here’s how: Most of the uninsured, the vast majority of the uninsured, people who go uninsured after redeterminations will have access to a subsidized plan in the exchanges, or will have access to coverage through either their employer or the employer of a family member and will turn it down. So, the vast majority almost no one who is uninsured after this will go without coverage or go without or not have a subsidized way to get coverage.

Joe: I thought a very persuasive part of your paper was not merely do you decide speculative information of a think tank that says this is what ought to happen or might happen. I thought it was a very interesting case you talked about Arkansas, which, you know, of all the 50 states while this pandemic was going on, they accepted the money, they waived eligibility requirements and they allowed everyone to enroll, but they kept track of how everybody did enroll and in a sense, preserve the records and it said, so that ultimately at the end of the pandemic they knew really amongst all their families who remained eligible. Say more about the case study that you included in your paper about Arkansas and how they did things differently.

Brian: Yeah, so Arkansas was one of the few states and they may be the only state that during the pandemic, continued to sort of do what they should be doing on eligibility like updating address information, updating employment records. So, when the pandemic when the public health emergency ended, and they could start doing redeterminations again, they were sort of ready to go they had identified the population that was likely ineligible. And if you’re trying to preserve resources—like this is one of the reasons we want states to do this—there’s a limited number of resources, we want them to preserve those resources to put them towards access for the healthcare system for individuals that remain eligible for the program. Arkansas was ready to do that. And Arkansas is now getting criticized for the large number of people who are coming off their Medicaid programs, but that’s largely a function of the fact that they were prepared and identified the individuals in advance that were likely to be removed when they were able to do eligible redeterminations.

Joe: I want to double back again I’m sure again our progressive list are thinking oh well you know Arkansas there, they’re there they seem inclined to want to again throw people off of Medicaid, but you mentioned and there are other instances I was surprised to read that many of the people who are ineligible are ineligible for the simple reason that they have a job so that they both have insurance at their job and Medicaid so they’re double covered, or they’re double covered because they moved from Mississippi to Alabama and they’ve enrolled in one place but didn’t disenroll in the other. Again, the old state had no incentive to disenroll them. They’re actually getting paid by the federal government per enrollee. So, the people who are enrolled in Medicaid either don’t know or they’re covered in multiple plans in multiple states. Say more about that.

Brian: Yeah, so actually last week I was talking to somebody in the Virginia, State of Virginia, who’s doing redeterminations there and they said they’ve uncovered two major problems. One is a large number of dead people on the Medicaid rolls that they haven’t been able to remove because of the redeterminations so he told me that they removed 30,000 dead people from the Medicaid rolls. And he said, he said with those individuals, they’ve been able to recover the payments that the state made to the managed care company on their behalf. Obviously, we don’t want taxpayers to be sending money to health insurance companies to cover individuals that are dead. Nor does the state want to be sending money to insurance companies to cover people who no longer live in the state. And he said there, they know that that’s a significant problem—that a lot of people have moved over the last three years he specifically cited people moving from Virginia to Tennessee. And he said, unfortunately, they’re precluded from making recoveries on behalf of people that have moved out of state. On the employer side, this is a major problem. You can see the employer plan is paying the insurance company for the individuals enrolled under the plan offered through the employer, and then Medicaid is paying for individuals, those same individuals, with taxpayer money, and those are payments that should not be made to health insurance companies, and we want to get individuals off the Medicaid program as quickly as possible so that they have employer coverage. So, again, so those taxpayer resources are free to pay for the healthcare and medical expenses of individuals that are truly eligible and that need the program.

Joe: Yeah, this is important because I think when people hear government program or welfare of the government program they imagine these checks that for better or for worse being sent to the wrong people—they’re not checks going to the wrong people there, they’re checks going to the wrong person’s insurance company so poor people are not benefiting from this, you know, redetermination it’s somebody else somebody in a suit and an insurance company. It’s not the poor people who are benefiting from these mistakes. And so, you know, since the government doesn’t have its own money, the money it wastes on improper, you know, ineligible people is money that’s can’t be spent on the eligible people—the poor, the sick, the old, the young, you know, say more about like who are the winners and who are the losers in this?

Brian: Well, I wrote an NRO piece, a National Review piece on this two weeks ago, and I brought up the story of the Baptist and bootleggers, and basically that story in brief is that the Baptist and bootleggers both had interest in prohibiting alcohol sales on Sundays. The Baptists wanted to do it for sort of moral reasons that people should be spending time with their family and bootleggers just wanted to sell more alcohol. So that was if you shut down the legal way that people could get alcohol, their revenue stream would increase. And whenever you look behind government programs, it’s very helpful to think about the Baptist and bootleggers, and it’s a perfect example here. The Baptist are sort of, you know, the community activists, the progressive organizations that want to make sure that everybody has healthcare coverage. The bootleggers are the health insurance companies. So, they are the main beneficiaries of keeping ineligible people on Medicaid for as long as possible. They’re getting payments, taxpayer money, that really they’re not entitled to—like these people aren’t eligible for the Medicaid program. And it’s particularly, again, egregious when the insurance companies are double dipping, which is—you gave one example, people in multiple states and then each state is paying insurance companies for Medicaid. And it’s the same thing with individuals that have both employer coverage and that have Medicaid.

Joe: Yeah, so again, I want to put at ease those people who are still sympathetic to the, you know, thinking about, okay, we’re going to sweep up a whole bunch of people who really ought not to be on Medicaid. But what about, what about that one person who really is eligible deserves it and somehow, you know, they’re not able — the worries about red tape or, you know, I think some of my progressive friends imagine poor people don’t have any agency or any ability, perhaps they’re old and they can’t understand the form, and we’re going to wind up sending out such, you know, complex forms, that when they ultimately do need care, they’ll have been kicked off Medicaid and not be eligible for that coverage. So, share with our listeners, do you think it’s possible in our zeal to make sure that there are no improper people on Medicare, might we be actually eliminating and causing harm to poor people who deserve Medicaid?

Brian: Yeah, so there’s a lot in that question. Let me start with the forms that people get. So, I talked to Arkansas about the way that they’re doing it. So, they said they try to get in touch with people three times of when their renewal is going to happen, they send them a notice 90 days in advance. They don’t hear from them, they send them a notice 30 days in advance. And then if you don’t hear from them, the week of their determination, they try to email call or text them to get ahold of them. And the forms that they send are pre-populated forms. So, they try to make it as easy as possible for the individual to stay enrolled in the Medicaid program so that the procedural disenrollments are really people that haven’t responded to these to these documents, and in some cases, not responding makes perfect sense. Like for the 5 million people to already have employer coverage, if you have a coverage through your workplace, you’d have no incentive, you have no incentive to return the forms and send them back in.

Okay, it’s just takes your time. And then I’m forgetting what the rest of your question —

Joe: No, I think what we were getting to is saying okay, you get a lot of chances to fill out these forms are pretty easy to fill out and you know once, twice, thrice, the state tries to make sure you’re there, and for a lot of rational reasons some people just don’t return the form, like I’ve already got coverage to my employer, I don’t need Medicaid, I’ll let it lapse don’t bother me and they don’t respond. But what about the person who isn’t able to respond? Let’s say they generally are, you know, so sick or, you know, have so many problems they can’t respond, they lose eligibility because they didn’t respond. What happens? Now, they go into the hospital, they’re poor, they’re young, they’re old. What happens to the person who has been pulled off a Medicaid when they show up the hospital.

Brian: Thank you for this question and reminding me of your original question because this is one of the main points that I’ve tried to make in my writing here, because the media in their covering of this unwinding process have almost universally failed to mention a core feature of Medicaid that protects those individuals. So, there are definitely going to be individuals who remain eligible for the program, who are removed in this process. There’s a feature of Medicaid law called retroactive eligibility. And basically, that means if you need medical services, when you are eligible for the program—say you have shown up at the hospital, you need medical services. The hospital can register you for Medicaid right there on the spot, and for most people your coverage is made three months retroactive, so Medicaid will pick up your expenses for three months. So again, it’s like, you are, if you are eligible for Medicaid, even though you’re not on the rolls because you’ve been removed, you remain effectively covered, because if you need medical services you can enroll in the program at that point in time and have Medicaid cover your expenses. And for most populations, it will cover them for the last three months that you incurred such expenses, so long as you’re eligible.

Joe: So, literally because of the retroactive nature of Medicaid, no one, no one can fall through the cracks.

Brian: Yeah.

Joe: Okay. Now, I wanted, there’s a couple of ways I want to take the question but given that Medicaid in a sense is double covering and you get that letter and you’ve got Medicaid and you have a private insurer potential, might some people say you know what, Medicaid is a better deal than I can get on my own. You know, maybe I’ll stay with it. Can that have a negative effect on the alternatives  toMedicaid as in the free market or the private small business health insurance?

Brian: Yeah, I mean, one, if you are eligible for private coverage, you really should not be receiving Medicaid. So, if you still are receiving Medicaid, and you have other types of coverage, Medicaid is supposed to be the secondary payer and the private coverage that you have is supposed to be the private payer. But yeah, I mean, Medicaid creates a whole bunch of distortions in the healthcare market. I mean, it’s government that’s setting prices, it’s government that’s setting reimbursements. There are potentially arguments of cost shifting where Medicaid is underpaying for services. So, there’s going to be higher reimbursements in the, in the private sector. But ultimately, I mean, I think one of the main things I want to do with Medicaid reform is—because I think the government’s going to subsidize healthcare and health coverage for low-income populations—let’s get the subsidy away from the insurance company and let’s get it to the individual, the recipient, and trust them to know how to best spend their money to get the care and coverage that works best for them.

Joe: Indeed. I want to, again, pivot to the idea that, of course, we talked about markets in our fondness for the people respond to incentives and we believe in market forces of individuals, but states also respond to incentives. And we may have, let’s hope we have some administrators and some legislators listening to the podcast and say, okay, yeah, sure, we’ve got some ineligible Medicaid people, but I got a lot of stuff on my desk. Why does this matter and, you know, why should I get busy trying to redetermine all the people that are in my state that really ought not to be on Medicaid? What incentives has the federal government or anybody done to incentivize states to get this job done and get the 15 to 18 million people off of these rolls?

Brian: Well, there’s a financial incentive. So, the state bears a portion of the cost of ineligible people still on the program. And if they are expansion enrollees, the states bearing 10% of the cost. If they’re non-expansion enrollees who are on the program who shouldn’t be, the states are bearing between 25 and 50% of the cost. So, there’s a clear financial reason. There’s also, I mean, just a what, like, if you’re a legislator that supports free markets and wants limited government, Medicaid is the biggest program. It’s the biggest welfare program that we have. I mean, how many people do you want enrolled in a welfare program that’s responsible for their healthcare. There’s natural crowd-out that occurs, both with, you know, Medicaid taking services for, you know, kids through less in education, you know, less state funding for transportation, for infrastructure. And it’s a major, it’s a major issue. It’s one, I mean, it’s Medicaid really with the open-ended federal reimbursement. It unfortunately can incentivize bad behavior at the state level to try to bring other stuff into Medicaid, because the stuff in Medicaid gets such a generous federal reimbursement. It’s really a need for conservatives for those of us who support a limited government, it’s one of the most important areas of where we need reform and where we really need fundamental restructuring of the relationship between the federal governments and states.

Joe: Indeed, that’s several podcasts worth of a conversation right there. Again, I’m talking to you from deep inside a very blue state. And so, we don’t have—you know we can’t make appeals to those who prefer the private sector to government-run programs. So, we’re getting close to the end of our time together. I’m sure we’ve piqued the interest of our listeners. I just want to, you know, I’m going to throw out a question I don’t know that your answer. How does Massachusetts, if you follow that. I did, there are a couple hyperlinks within your paper to research that tracks spending. Ironically, despite the directive to reduce the number of people on Medicaid in every state, our numbers have been going up for the last couple of months. So, the news hasn’t reached Massachusetts yet. Do you have any idea, we always—is there a plan here, or in states like Massachusetts, or are they going to essentially ignore and hang on to these ineligible enrollees, as long as they can?Brian: So, I would have to go check my notes in terms of when Massachusetts is going to start redeterminations. I know that they’re starting this summer. I they’re probably starting in July. And, or maybe, I guess, you’re saying they’ve already started because they’ve had an increase in the number of people on the program. That is not going to last, like there are hundreds of thousands of additional people on Medicaid in Massachusetts right now, because of this process. And most of them in Massachusetts will probably migrate. They’ll either migrate, they’ll be in the employer-sponsored insurance market, or they’ll be in the Obamacare exchanges in Massachusetts. But either of those, I mean, you’re going to have significant state savings when you move those populations. So, I think—I can’t explain why the redetermination process would have increased or why Medicaid enrollment in Massachusetts would increase despite the redetermination process. My sense is that it’s just an anomaly and maybe they started with categories of enrollees that were least likely to be removed from the program. So, they’re going to keep people on the program as long as possible.

Joe: Now, if you were king for a day and you were going to help Massachusetts get to where they need to go, where would you start? Do you just assume—do you look for the double-enrollee, the people who have income that makes the ineligible, but you look for folks who are 18 or 19 and then they leave chips and go into something else? Where would you start? Do you go with the big pile, or do you start with the As and go to the Zs?

Brian: Well, I would start with the individuals who are most likely not eligible for the program anymore, right, so because you, that’s one, what the state’s financial incentive is, the quicker they remove people that aren’t eligible, the less they’re spending of the state resources on that population. So, there’s basically, there’s a couple of categories. One is the age. So, people that have aged into Medicare for the most part, they shouldn’t be on Medicaid anymore. And the same thing with the kids. Once they turn 19, you want to do a redetermination there, but you’re really trying, and states have all of these like databases they can match, or you can get a vendor to match Medicaid enrollment with commercial enrollment and commercial plans. And that’s where I would start, because that’s where you’re going to get the biggest bang for your buck, or people that are double-covered on Medicaid and a commercial insurance plan and process those removals as quickly as possible.

Joe: So, let’s hope that the administrators and legislators are listening to the show want to use those monies that are being effectively wasted by sending them to insurance companies unnecessarily, and want to reapply those monies to the truly worthy members of Massachusetts who deserve the help. So, we’re running out of time. I want our listeners to read more. This is a complex topic. I think we were brave to try to tackle it in a half-hour. Where can our listeners learn more about your writing and Paragon Institute?

Brian: Sure. So, thank you for that. They should go to paragoninstitute.org or just Google Paragon Health Institute andyou’ll see there are several tabs of our initiative areas and click on the Medicaid initiative tab, and you’ll get all of our most recent reports and commentaries on this issue.

Joe: Again, yes, I found your writing wonderful and whether one wants to see more of a market solution or a government solution at the end of the day we want the government to be helping those who deserve the help and protecting the money, taxpayer money at the same time so thank you for your research your work your writing and thank you for joining me on Hubwonk today, Brian.

Brian: Thank you very much, pleasure to be here.

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