RX for states: Expand Medicaid -- June 13, 2013 column

By MARSHA MERCER 

“Americans can always be counted on to do the right thing – after they have exhausted all other possibilities,” Winston Churchill supposedly said.

Whether the remark reflected Churchill’s or someone else’s wit, we again are seeing Americans struggle over the right thing. This time the right thing is for every state to expand Medicaid, the joint federal-state health insurance program for the poor.  

Medicaid currently provides health care to about 59 million low-income people – mostly young children and their parents and pregnant women. It pays for long-term care for seniors in nursing homes and people with disabilities. Some states, like Massachusetts, expanded Medicaid coverage on their own.

In March 2010, President Barack Obama signed the Affordable Care Act – a.k.a. Obamacare – which aims to bring affordable health care to most Americans no matter where they live.

The law is making significant changes. Next year, insurance companies can no longer discriminate against people with pre-existing health conditions, and almost every American will have to have health insurance or pay a tax penalty. The law also required every state to expand Medicaid to cover people with incomes up to 133 percent of the federal poverty level, about $26,000 for a family of three in 2013. The Congressional Budget Office said the Medicaid expansion would provide 16 million Americans with reliable health care.   

Republican state officials challenged the law in the courts. Last June, the Supreme Court upheld the law but said expanding Medicaid was a state option. Today 22 states and the District of Columbia are moving forward with the Medicaid expansion, according to the Kaiser Family Foundation. These include California, Minnesota, New Jersey and New York.

About 20 states have rejected the expansion – at least for now. Among them are Alabama, Florida, North Carolina, Oklahoma, Texas and Virginia. Eight other states around the country are still fighting it out.

In five Deep South states that have opted out – Alabama, Georgia, Mississippi, Louisiana and South Carolina – 62 percent of residents support the Medicaid expansion, a poll in March and April by the Joint Center for Political and Economic Studies found. The center is a public policy research group that focuses on African Americans.

Virginians were almost evenly split in March with 45 percent favoring expansion and 43 percent opposed, a Quinnipiac University poll reported.    

States that have rejected the expansion have some of the nation’s worst health records. America’s Health Rankings, an annual report by United Health Foundation, ranked Mississippi and Louisiana 49^{th,  --} the least healthy states. Alabama is 45^th and Virginia 21^st.

The states are forgoing “free” money. The federal government will foot 100 percent of Medicaid expansion costs from 2014 to 2016. Repayment will drop  to 90 percent in 2020 and level off after that. That’s a much better match than states currently have for Medicaid. The federal share ranges from 50 percent to 83 percent, with poorer states getting higher amounts per capita.   

Critics of expansion say they worry about unspecified costs down the road, and yet people without health insurance get health care every day in more costly hospital emergency rooms.    

A new Rand study of the first 14 states whose governors declared they would not expand Medicaid, including Alabama, found those states together would spend $1 billion more on uncompensated health care in 2016 than if they expanded Medicaid. The 14 states would give up $8.4 billion annually in federal payments, Rand said.

An analysis of state health data by the Los Angeles Times indicates that the states could use the help. Colon cancer deaths in states that oppose the Medicaid expansion are, on average, 16 percent higher than in states that support expansion, and deaths from breast cancer are 8 percent higher on average in states that oppose the expansion.

“Medicaid by itself may not close those gaps, which also reflect income and education disparities,” the paper reported, noting that conservatives argue that poor people would be helped more by alternative strategies that encourage people to take responsibility for their own health care.

States that don’t expand Medicaid still face other higher costs. Nationwide, only about two-thirds of people eligible have signed up for Medicaid, and the new health law includes a major outreach effort.

The fight over Medicaid is far from over. There’s no deadline for expansion, and supporters say they’ll be back in statehouses for the next legislative session. As they say in baseball, there’s always next year.

For now, though, it appears many states are determined to ignore the proverb and be “penny wise and pound foolish.”   

©2013 Marsha Mercer. All rights reserved.

Supremely kicking the uninsured -- July 19, 2012 column

By MARSHA MERCER

When the U.S. Supreme Court upheld almost all the Affordable Care Act last month, analysts gushed that it was a stunning victory for President Barack Obama.

It’s becoming clear, though, that the court’s ruling on the Medicaid provision may be a bitter disappointment for low-income workers who are uninsured, especially in the South.

A central promise of the Affordable Care Act is that it will relieve the anxiety and financial insecurity of having to live without health insurance. Most of the uninsured have jobs or live in a household with someone who does, but their employers don’t offer health insurance, they aren’t eligible because they work part-time or they can’t afford the premiums.

Obamacare, as the law is known, provides carrots and sticks for people to obtain affordable health insurance. That’s where Medicaid, the nation’s largest health program in terms of participants, comes in. About 60 million Americans receive health care through Medicaid. About three-fourths are poor children and families and one fourth are elderly or disabled. Seven in 10 nursing home patients are on Medicaid.

The idea was to bring coverage to about 16 million more Americans by 2019 by adding a new category of Medicaid eligibility: adults without children who are under 65, not disabled, and whose income is near the poverty line.

The law presented states with an offer they couldn’t refuse: Expand Medicaid in 2014 to people whose incomes are within 138 percent of the federal poverty level -- $26,344 for a family of three in 2012 -- or forgo all existing federal Medicaid funding.

But Chief Justice John G. Roberts Jr., writing for the majority, said such “economic dragooning” left states no real choice but to participate in the expansion. The court struck down the funding restriction, and states now have the option of rejecting the expansion and sticking with their current Medicaid program without penalty.

Sadly, that means health coverage now depends on geography, with many low-income Americans who can’t afford insurance in limbo and at the whim of their governors.

So far, only a handful of governors will definitely implement the expansion. About a dozen governors, many in the South, have said they may or will reject expansion.Republicans Rick Perry of Texas and Rick Scott of Florida will reject. Those leaning against expansion include Alabama Gov. Robert Bentley and Virginia Gov. Robert F. McDonnell, both Republicans. Tennessee Gov. Bill Haslam, a Republican, is mulling whether to ask for a block grant to run his state’s program. A lump sum payment would come with fewer strings as to how the program operates.

The governors say their main worry is cost, and yet the federal government will pay for expanding Medicaid at first. Uncle Sam will pay 100 percent of the costs for new enrollees for the first three years. After that, states would begin sharing in the new costs, up to 10 percent.

Turn down free money? Highly unlikely, the Obama administration thought. Some veteran political watchers still predict balky states won’t turn down the money come the 2014 election cycle.

The court has left the decision up to each state at a time when the fiscal and political forecast is stormy. A new report on states’ fiscal health by respected economists predicted financial woes that will last long after the economy finally rebounds.

Complicating the matter is a provision in the health law that says those who don’t qualify for Medicaid will be able to get insurance through new marketplaces called exchanges. Those who can’t afford the premiums will be eligible for subsidies.

States are expected to set up the exchanges, but many states have been slow to get started. As with the Medicaid expansion, some may pass. If a state won’t set up an exchange for its residents, the federal government will step in. But there’s yet another catch.

The law says that the uninsured can get subsidies for premiums on state-run exchanges. It doesn’t say subsidies will be available for premiums on federally run exchanges.

That glitch too can be worked out – if there’s a will.

For now, millions of working Americans who lack insurance are still pawns on the great political chess board. And that’s a shame. We can and should do better.

© 2012 Marsha Mercer. All rights reserved.

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