Am I missing something here?

Lizette Alvarez, in the NY Times, makes a big deal out of a proposal in Florida to move most Medicaid recipients into managed care. This is presented as an "experiment" in which "Florida lawmakers are poised to scrap the traditional model in which the state pays doctors for each service they perform."

Uh, Liz. Right now, today, as John Iglehart reports in NEJM, nationally, "fee-for-service payments to physicians make up only a minuscule portion (3.1%) of total Medicaid spending, since states, seeking savings, have increasingly contracted with managed-care plans." Florida is way behind the curve on this. As Iglehart further informs, "A key feature of budget-cutting exercises in virtually all states where managed-care plans operate is an increasing reliance on those plans to enroll Medicaid beneficiaries. In 2009, 25 states had more than 50% of their beneficiaries enrolled in such plans, but they were mostly mothers and children — Medicaid’s least expensive patients. A new trend in some states is to make enrollment in managed-care plans mandatory for elderly, blind, and disabled Medicaid beneficiaries."

Now, I don't actually have a problem with managed care for Medicaid recipients, as a generic concept. In fact, Accountable Care Organizations, which are encouraged for Medicare and private health insurance plans in the PPACA, are really a version of managed care, designed to overcome some of the problems and consumer dissatisfaction that arose during earlier attempts to implement managed care in the 1990s. I've always said that fee for service is not a good way to pay for health care, that what we need is a way of paying for results, and managed care is essentially a broad term for trying to do that.

Problems arise when you a) don't pay enough to get decent results now matter how well you manage the care; b) define "management" as denying services and do it crudely and inappropriately; c) make patients and doctors go through bureaucratic obstacles which in fact waste money (and time) and frustrate all concerned; or d) don't provide adequate protection for the most vulnerable and sickest people who are likely to come out badly if you aren't very careful and precise in how you go about this.

Right now, all the Republicans seem to care about is spending less money so they build in point a -- don't spend enough -- from the beginning and don't care what happens with b through d, which a fortiori means nothing good will happen.

Unfortunately for our political discourse, the specifics of how to avoid these pitfalls are mildly complicated. They don't involve death panels but they do involve changing the ways in which physicians practice and putting less money into narrow specialties and more into primary care, among other goring of oxes. It's so much easier just to say we're going to turn Medicaid into a block grant, pay less for it, and let the states deal with the consequences. Easier, but also profoundly evil.