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Rob Natelson: On the Medicaid Expansion—Yes, Montana Should Say No

When the Supreme Court’s Obamacare case was pending, I noticed that while there was a lot of attention given to the individual insurance mandate, there was little discussion of the Medicaid expansion.

The Medicaid extension was the part of the law that sought to force states into signing up for an expensive new program by threatening to cut off all Medicaid funds if they did not.

Whether the individual mandate was constitutional was an arguable question under the Supreme Court’s modern jurisprudence.  (As you probably know, the court’s modern law on federal regulation and spending is largely disconnected from the Constitution’s actual meaning.)

But the Medicaid mandate was different. However, I looked at it—under modern law or the Constitution’s actual meaning—that mandate seemed flagrantly unconstitutional to me. But almost no one was addressing it.

As a result, I authored one of the very few Supreme Court briefs to address the issue in detail. The brief was edited and filed by Dave Kopel at the Independence Institute, where I am also a senior fellow.

Against all popular expectations, we won: By a 7-2 margin, the Supreme Court struck down the coercive portion off the Medicaid expansion. This left the states free to make their own decisions.

A recent MPI post explains why Montana should not sign up for the budget-busting, dependency-creating Medicaid expansion. As if any additional reasons were necessary, health care expert Linda Gorman adds this compelling argument. It’s written for Colorado, but applies to Montana as well.

The Health Care Debate Debate

I just posted a Medicaid expansion op ed that argues, pretty effectively I think, against Governor Bullock’s plans to expand Medicaid eligibility to 138% of the federal poverty level. Those things are limited to 700-800 words, though, so I couldn’t include anywhere near all of the reasons that this is a bad idea, both for taxpayers and for potential enrollees.

The moral case against expansion is that the preponderance of literature indicates Medicaid patients have worse healthcare access and outcomes than the privately insured.

This is primarily because Medicaid reimbursements often don’t cover provider costs, so fewer providers are accepting Medicaid.
That means Medicaid recipients have insurance but not necessarily care, and so they end up in emergency rooms sicker and with more serious conditions than those with access to care through private insurance. Obamacare’s planned cuts to both Medicaid and Medicare reimbursements will only exacerbate this problem.

A few states like Florida and Rhode Island have tried consumer-driven Medicaid reforms that have actually decreased costs and increased access to care rather than simply drive more people into an unhealthy system. What a concept, except that those options were pretty much cut off from other states under Obamacare.

As for the impact on taxpayers, the Heritage Foundation has a good report for state lawmakers outlining the hidden costs of Medicaid expansion. Give it a read, and then contact your Representative or Senator to let them know how you feel.

And then, if all this piques your interest about consumer-driven healthcare reform, consider that if Switzerland can do it to great effect so can we.

It’s really pretty simple. As a society we’ve made the correct decision that we’re not going to step over bodies on the way to the hospital. So we subsidize those who need it, but we still offer them choices in what care they receive and how they get it. That results in insurers and providers competing for their business, which results in better service, better care, and lower prices. It works for virtually everything else we purchase, so why not healthcare?

Now Is Not the Time for Medicaid Expansion

 Bozeman – Governor Bullock has decided to ignore the Schweitzer administration’s budget submitted last November and instead opt into Obamacare’s Medicaid eligibility expansion. This looks to be a patently bad idea; and even if it’s not there’s no reason to rush forcing Montana’s taxpayers into yet more unsustainable entitlement spending and to herd more of our citizens into a system that provides inferior care at great expense.

First let’s get a little background out of the way and then I’ll explain why it’s a bad idea.

Medicaid provides health insurance – not necessarily health care, but more on that later – to families with incomes up to 133 percent of the federal poverty level (FPL). Montana’s taxpayers currently pay about 33 percent of the program’s cost, with the federal government picking up the balance.

Last summer’s Supreme Court ruling let states decide whether to increase Medicaid eligibility to 138 percent of the FPL, which Obamacare tried to mandate. Many people portray this as “free money” since Washington says it will cover almost all the costs until 2017 and then ramp down to 90 percent of the costs after that. But that promise, like so many others that were made during the health care reform debate, simply doesn’t match the facts on the ground.
These facts argue against expanding Medicaid eligibility for two major reasons, one of them financial and the other one moral.

The financial reason is that we already know this expansion isn’t “free money” for the state. And the moral reason is that it will result in thousands of Montanans being dumped into a system that results in inferior access to care, with many of them forced out of much better private insurance plans.

Estimates of Montana’s potential share of expansion costs vary pretty wildly[i] but most come in between $100 million and $200 million,[ii] or the equivalent of between two hundred and four hundred new teachers, for example.[iii] Our costs increase for a lot of reasons, but I’ll just highlight a few obvious ones.

First, with Obamacare scheduled to cut $8 billion from Medicaid and $500 billion from Medicare, you can be sure that Montana’s health care providers will be coming to taxpayers to be made whole when their costs inevitably outpace their reimbursements under these government programs.

Next, the largest single increase will result from people who are eligible for Medicaid at the 133 percent FPL rate, but not currently enrolled, coming out of the woodwork as word gets out that eligibility has been expanded. Many of these people are technically uninsured today but would be enrolled in Medicaid and receive care if they needed it. Many others, though, have their own insurance and would simply shift from private to public coverage. Since they wouldn’t meet the new 138% FPL threshold, about 33% of their insurance costs would be shifted from them or their employers to Montana taxpayers.

And finally, for anyone who believes that the federal government will continue to reimburse states at the 100 or even 90 percent level, well, I’ve got a bridge to sell you. Washington’s budget woes are going to be transferred to the states, and states like Montana that get from Washington much more than we give are going to feel the pain first and most acutely.

Shifting our most vulnerable population to Medicaid is also immoral. Studies consistently show that Medicaid patients have poorer access to care than privately insured patients.[iv] Since Medicaid typically pays physicians 56 percent of the amount private insurers pay, fewer doctors are accepting new patients and they eventually wind up in hospitals with more serious conditions than those who are privately insured. In addition, there’s scant reliable evidence that Medicaid improves health outcomes at all, and zero evidence that it is the best way to improve health outcomes per dollar spent.

Expanding Medicaid will only worsen our health care system’s woes, increasing costs and decreasing access to quality care while adding a new entitlement burden on taxpayers and dumping thousands of low income Montanans into a failing program. There’s no rush to expand. If it works for other states we can always sign on. But this is one case where we shouldn’t lead with our chin.

Carl Graham is CEO of the Montana Policy Institute
 

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[i] MT Department of Public Health and Human Services, “The Impact of Medicaid Eligibility Expansion and health Montana Kids Monitoring,” 12/2/2011, http://leg.mt.gov/content/Publications/fiscal/interim/financecmty_dec2011/SJ%2026%20ACA%20Medicaid%20expansion.pdf.
[ii] For example, Kaiser Commission on Medicaid and the Uninsured, “the Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis,”  11/2012, http://www.kff.org/medicaid/upload/8384.pdf.
[iii] Derived from data at teacherportal.com, http://www.teacherportal.com/salary/Montana-teacher-salary.
[iv] For a synopsis see The Heritage Foundation, Kevin D. Dayaratna, “Studies Show: Medicaid Patients Have Worse Access and Outcomes than the Privately Insured,” 11/9/2011, http://report.heritage.org/bg2740.

Enough Already! – National Debt to Skyrocket

Our friends at the Heritage Foundation have some pretty nifty charts that put our current national fiscal crisis into perspective. Here’s a sample: