I interviewed a prospective medical student the other day and the discussion moved to the Affordable Care Act, patient responsibility, and rationing care. We both agreed that care was rationed currently in this country, mostly by ability to pay (or luck of having health insurance). We also agreed that ability to pay was a poor discriminator and a “safety-net” was necessary should universal coverage be beyond our grasp as a country. Since 1965 that net has included of Medicaid for the very poor and disabled. I explained that the Affordable Care Act expands that net to make it one of the key components of a scheme to provide near universal coverage. I also explained that the ACA was not meant to be the end but the start. It is up to us to make the system more effective once the advantages of gaming the system through care denial and “pre-exist” clauses are taken away.

Though Governor Romney has made it clear that want to repeal the ACA (on Day 1), he also believes a safety net is necessary. It is unclear in his administration who would pay for the safety net, what the net would look like (other than that charities and emergency departments would be forced to take folks), and who would be caught in the net. A study (reported in Medpage Today) sheds some light on the size and shape of the proposed new net based on information available:

The plan offered by the Republican presidential ticket to turn Medicaid into a block grant program run by the states would cut enrollment in half, a study found. Between repealing the Affordable Care Act (ACA) and its Medicaid expansion and moving to a block grant program, the plan proposed by GOP vice presidential nominee Rep. Paul Ryan (R-Wis.) would cut enrollment between 31.3 million and 37.5 million.

It would save a lot of money

Ryan says the move will save up to $800 billion in 10 years. The Urban Institute report says repealing the ACA and moving to a block grant would save $1.7 trillion in the next decade.

But at a cost. As a safety net, the holes would be larger

“The proposed changes and reductions in federal financing for Medicaid under the House Budget Plan would almost certainly worsen the problem of the uninsured and strain the nation’s safety net,” read the report, which was commissioned by the Kaiser Commission on Medicaid and the Uninsured.

And fewer people would likely be working the nets

Not only would enrollment fail to make up for the lack of Medicaid spending, payments to providers would also suffer, the report said. “Payments to providers could fall by 32% relative to the baseline,” it noted.

But the good news is, well, there is no good news

“Medicaid’s ability to continue [its] many roles in the health care system would be significantly compromised under this proposal, with no obvious alternative to take its place,” the report concluded.

Maybe, a different net??