Just Sayin'

Paul Adair is a 21-year Germantown resident, retired scientist, writer, and lecturer.

Them As Has, Gits

Political, U.S., Healthcare

A Supreme Court decision in June 2012 rightfully confirmed the constitutionality of the Affordable Care Act. However, it also included a tragic edict. It allowed the “states” to opt out of the expansion of Medicaid to all citizens with incomes less than 138% of the federal poverty level (FPL). In reality, it allowed the states' governors to opt out of Medicaid expansion, in most cases overruling the will of the people.

But even in red states like Ohio, Michigan, Arizona, and North Dakota, Republican governors understood the foolishness of denying health care to thousands of their poorest residents. These states' leaders convinced their legislatures to accept federal funds to expand their Medicaid programs. To do otherwise would be financial and ethical malpractice-covering fewer people at greater expense to the state.

Under the original Affordable Care Act, all citizens up to 138% of poverty level are covered under expanded Medicaid. Those between that 100% and 400% of FPV are eligible for tax credits to purchase private insurance on the exchanges. After the Supreme Court decision, some backward states opted out of the expanded Medicaid program. Some of the opt-out states do not cover single adults under Medicaid and many set their maximum Medicaid income levels at a fraction of the FPL.

This left many people, those who are ineligible under state Medicaid rules and make less than 100% of FPL, with neither Medicaid or exchange subsidies. An estimated 5.2 million very low-income Americans fall into this gap. (And just try to get this Congress to do their job and fix that problem!)

The states' Medicaid expansion decisions are are still in flux. For example, Virginia's recently elected Democratic governor campaigned on expansion. Other states, such as Pennsylvania, Maine, Florida, and Wisconsin will likely expand Medicaid after voting-out intransigent Republican governors later this year. Currently, 26 states and D.C. have expanded Medicaid, while 24 states have opted out.

Ironically, states opting out (mostly states under long-term Republican control) tend to be those with poorer healthcare to begin with. Years of lax workplace safety standards, weak environmental regulation, and minimal insurance coverage of poorer citizens have led these “conservative” states to have poorer health outcomes. The Medicaid opt-out by these states will only magnify the future difference between them and more progressive states.

The non-expansion states were already somewhat behind with respect to the percentage of residents insured before the ACA changes on January 1. The average non-expansion state had an uninsured population of 15.5%. The average Medicaid expansion state had an uninsured rate of 13.3%. And these averages mask the truly horrendous uninsured rates in the non-expansion mega-states of Texas (24.3%) and Florida (20.7%)

One measure of state healthcare outcome is the life expectancy of a newborn resident. The average state life expectancy in expansion states is 79.1 years vs 78.1 years in non-expansion states. Of the top 10 states in life expectancy: Hawaii, Minnesota, Connecticut, California, Massachusetts, New York, Vermont, New Hampshire, New Jersey, and Utah, only New Hampshire and Utah are not expanding Medicaid.

Of the ten shortest lived states: Georgia, South Carolina, Tennessee, Kentucky, Arkansas, Oklahoma, Louisiana, Alabama, West Virginia, and Mississippi, all but three (KY, AR, WV) are heinously rejecting Medicaid expansion. Many of the desperately poor in these states will continue to be without access to needed health services.

Another objective measure of health care outcomes is the age-adjusted mortality rate per 100,000 people per year. The death rate average in the non-expansion states is 793. That of expansion states is a substantially lower 737. Again, the states that have progressive governments already have better healthcare outcomes. The expansion in these enlightened states will only make outcomes better.

What about the healthcare infrastructure? One way making a state-by-state comparison is to consider the number of doctors per 100,000 population. Surely, the more doctors, the better access to medical care. The 26 Medicaid expansion states (+ DC) average a hefty 304 doctors/100,000 people. This compares to the 24 opt-out states with an average of only 232 doctors/100,000.

The gubernatorial decisions to reject Medicaid expansion were made for ideological reasons, not based on rational analysis. For example, the Walkercare scheme will cost Wisconsin taxpayers $459 million more through 2021 and will cover fewer people. And the decisions certainly ignore the will of the electorate. A May 2013 poll of six non-participating deep South states found Medicaid expansion favored by a 62-33% margin. In deep red Texas, voters prefer Medicaid expansion by 54-34%.

The progressive states that have expanded access to quality healthcare for their citizens through Medicaid also tend to be ones whose past policies led to better healthcare outcomes. With most of their citizens now having medical insurance, the differences will become even more pronounced. We will become truly a nation of healthcare have and have-not states. It appears that in the healthcare world, as in the financial world, “them as has, gits.”



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