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Posts tagged as “Medicaid”

Medicaid expansion: more harm than good?


NNU economics professor Peter Crabb recently opined that expanding Medicaid coverage to approximately 62,000 Idahoans “is likely to do more economic harm than good.” His thesis is that people who get government health coverage are more likely to engage in risky behavior and therefore require more medical care. Where to start?

The people who will be covered by Medicaid expansion are working people who make too much to get Medicaid, but not enough to get subsidized health coverage under the Affordable Care Act (ACA). The prof worries that these people will have little incentive to stay healthy if they get “free lunch” government health care. If you are barely making enough to feed and shelter your family, you have a strong incentive to stay healthy so as not to lose your paycheck.

If the prof is correct, there are already hundreds of thousands of Idahoans doing things that are hazardous to their health because they receive government help. About 240,000 of us are getting Medicare, almost 300,000 are on Medicaid and Children’s Health Insurance, and about 125,000 are getting insurance through government jobs. Medicaid expansion would add only about 62,000 people to the list of Idahoans getting government help for medical care, which would probably not greatly increase the risky behavior factor.

Many more Idahoans get insurance through their jobs, and their employers can justifiably deduct it from their taxes. Veterans and retired military deservedly get government health coverage. And let’s not forget the many thousands who get subsidized insurance through the ACA. Why should the government subsidize almost everyone else’s health care and not the people in the coverage gap?

As for cost, Milliman, a highly regarded actuarial firm often used by the state, recently reported that Medicaid expansion could actually save the state up to $15 million per year by eliminating the need for the state’s Catastrophic Health Care Fund and the county indigency programs. The indigency programs are a real drain on the counties because they pay for often routine medical care at emergency room rates.

Perhaps the best way to find out what expansion might do is to see how it has worked in the 33 states that have expanded Medicaid to get the many millions of federal dollars available. When Ohio expanded its program, an additional 700,000 people got Medicaid coverage. Governor Kasich reports that 290,000 of those have since left the program. Most of them told the state that having the insurance helped them find or keep their job. And, one would suppose those people are contributing to Ohio’s economic well-being.

As far as the economic impact of Medicaid expansion, the infusion of federal money will create many additional health care jobs for Idahoans, help keep rural hospitals financially solvent, and keep that money circulating and multiplying through our communities. It will allow people with routine illnesses to get medical care before their conditions turn into expensive medical emergencies that taxpayers will pay for either directly or indirectly.

And, in the final analysis, isn’t it the morally correct thing to do? Why should people who are working hard to take care of their families have to choose between bankruptcy or death when they are confronted with a serious illness? Especially when almost everyone else in the state gets at least some “free lunch” medical help from the government already?

Let’s approve the Medicaid expansion initiative on the November ballot. It is the right thing to do, economically, morally, and equitably.

Unintended consequences


The true heart of the Affordable Care Act, sometimes referred to as “Obamacare” but termed here as simply the ACA, is the structure it provides for the maintenance of adequate, portable, comprehensive and reliable private health insurance to all of us and our families.

For most of us the impact of this law and the changes it wrought have been invisible. For the healthy among us, who were happy to remain in the same employment with already adequate insurance, who did not encounter disastrous illness or injury, and who were without disabled children, the advent of the ACA brought nary a ripple.

One sizable bunch did see an immediate benefit. The self-employed, such as small-firm professionals and the like, who might have been paying for health coverage at very high individual private insurance rates, and the part time or low wage employee who did not receive insurance from their employment and could not otherwise afford private policies, both suddenly found adequate health insurance available through state exchanges at rates equivalent to that charged large employers and groups, and with significant federal subsidies for the lower rungs of qualified individuals.

While there were many process problems getting the bugs worked out of the exchange machinery, there have been few complaints over the products that popped out, or to the ultimate cost of it to the qualified participants. These participants have joined the majority in enjoying adequate, non-cancellable, portable, comprehensive and reliable private health insurance at an affordable cost.

Not so much is heard of any of the essential changes brought about by the new law, for the simple reason that they appear to be working exactly as designed. For the first time ever, most of us no longer worry about a catastrophic illness or injury blowing through the ceiling of our health insurance, or having a company cancel coverage in the middle of difficult times, or of being chained to ill-fitting employment because of the risk of being trapped by a preexisting condition clause, or of having a recommended treatment denied by bureaucratic action with no recourse to have the matter reviewed or reconsidered, or of keeping adequate coverage for a child all the way through college.

These matters do not affect most of us, but for the millions and millions who have been affected by any one of these elements in their lives or the lives of their loved ones dependent upon them, the saving provisions of the ACA have provided immeasurable relief and peace of mind.

The only foghorn clamoring away, usually from the right, has been connected to the fact that premiums have gone up. But the ACA doesn’t touch premiums; it is based on private insurance, which requires private payment of premiums, which is connected to actual costs. From the beginning it was made clear that health care costs would be going up, and premiums were going to rise. The major omission the critics make is in failing mention that premiums have not increased as fast or far as was predicted without the adoption of the ACA. The rate of growth of health care costs has flattened, and the increases that are coming are not as great as once feared.

All of this means that for most of us, we have grown complacent; the ACA is working just fine, thank you, and we would not like to see any of it lost. The few of us who are complaining about the cost would complain anyway – with or without the ACA. Notwithstanding the campaign rhetoric coming from the parade of Republican beseechers, we all know there is no realistic political chance that the country is going to reverse course on health care now. Too many of the core provisions are proving to be too valuable and too popular for anyone to seriously suggest a complete repeal. Even the wannabees, when pressed on details, hide behind promises to save the best provisions of the act which, when one tracks down and adds up all the promises, turns out to include it all.

There is this nagging problem. Through the willful act of several of the states, including Idaho, the ACA is not being permitted to fully engage the entirety of the health insurance coverage that was expected. The individuals left at risk are among the very poor and helpless – those without clout or means, and who are now being ignored for the very worst of reasons – spiteful politics.

Under the ACA, everyone who is gainfully employed or occupied is supposed to be guaranteed access to affordable health coverage, either through their employer or through a state exchange. The exchange is available to anyone who is employed but does not receive insurance through employment or who is self-employed. The coverage is still private coverage by private insurers, although the premiums may be subsidized for qualified individuals. The purpose of the exchange is two-fold: (1) to make insurance available at what amounts to group rates, rather than individual rates, and (2) to establish subsidies where needed. To make this work, it is required by the act that a participating individual have some level of income, measured at a percentage of the poverty level established for the state, in order to qualify for private health insurance through the exchange.

The requirement for a floor level of income to participate through an exchange meant that those individuals who earned less than the required percentage to qualify for insurance through the exchange, but who, for any of a variety of reasons, might not qualify for standard Medicaid – would remain uninsured. In Idaho, for example, this gap consists of approximately 78,000 individuals, all uninsured.

The solution under the ACA was to provide that the states would increase the eligibility level of Medicaid to include by definition all individuals in this gap. This expansion of Medicaid is fully funded under the ACA, with all revenue measures in place. There will be no cost to the states at all for the first 10 years of the ACA; after that, the federal government will pay 90% of the increased benefit cost, with the states paying 10%.

No one anticipated what actually happened. The Supreme Court struck the mandatory provision for expansion of Medicaid. And, despite the fact that it is integral to providing seamless coverage to the poorest, despite the fact that it is fully funded for ten years so comes at no cost to the states, and despite the fact that by not buying into the Medicaid expansion, the states gives up hundreds of millions of dollars in federal grants – 26 states declined to expand, and continue to decline to expand their Medicaid programs.

One of those states is Idaho. The governor and the legislature refuse to even consider the expansion bill. A bill for the expansion has been introduced every year, but has yet to be mentioned by the Governor in his state of the state message, or to see the floor of either house for a vote.

If Medicaid were so extended, the ACA would provide a seamless blanket of coverage available to essentially everyone. In Idaho, the expansion of Medicaid could replace almost the entirety of several state and county programs for indigent care and catastrophic care, currently running state and counties approximately $63 million per year. The benefits, which might have been paid to medical providers in Idaho on behalf of this group for the current years, have been estimated to be in the range of $73 million per year. If one adds these resources together, Idaho has already watched close to $272 million slip through its fingers by not expanding Medicaid originally, and the state is losing somewhere in the range of an additional $136 million per year for every year it does not act.

This is not all. We, or at least some of us, are paying those specific federal taxes created within the ACA for funding the expansion of Medicaid nationwide. No credit exists or refunds for those states that have not gone along. Our money derived from these tax sources within Idaho is not being returned to our state, and must be added to the losses sustained by Idaho for not approving the expansion.

As Idaho heads into the third legislative session since the rollout of the ACA, the subject will come up again. Every single outside interest group that has looked into this has recommended expansion. Other alternatives to expansion are woefully inadequate and there is no valid, logical reason for continuing to withhold. Perhaps the wisest of the group who will be assembling here next week will see at last that there is no U-turn on the horizon for the ACA and that money is money is money.

Pry the thing out of committee and pass the damn bill.

Expanding Alaska Medicaid


These days “new” money is hard to find. That’s the kind of money that’s added to a budget, money that allows programs to expand, try out new ideas, and look for ways to make life better. Most government budgets are doing the opposite: Shrinking. Calling on program managers and clients alike to do more with less.

That’s why the news from Alaska last week is so exciting: Alaska’s new governor announced the expansion of Medicaid and this will significantly boost money for the Alaska Native medical system. Indeed, the significance of this announcement to the Indian health system was clear when Alaska’s Gov. Bill Walker and Department of Health and Social Services Commissioner Valerie Davidson made the announcement (pictured) at the Alaska Native Medical Center on July 16. The governor took this action using executive authority because the Alaska legislature had failed to even vote on legislation to accept Medicaid.

The governor says Medicaid expansion would reduce state spending by $6.6 million in the first year, and save over $100 million in state general funds in the first six years. “Every day that we fail to act, Alaska loses out on $400,000,” the governor said. “With a nearly $3 billion budget deficit, it would be foolish for us to pass up that kind of boost to Alaska’s economy.”

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“We know Gov. Walker has worked tirelessly to expand Medicaid since he came into office on December first,” Davidson said at the news conference. It was one of the campaign promises made by the independent governor. “He included it in the budget. He introduced a bill both in the House and in the Senate side. It was a subject of both special sessions. And, it’s the right thing do do for Alaska.”

The expansion of Medicaid is one of key components of the Affordable Care Act. It’s critical a tool for the Indian health system because it opens up a revenue channel for clinics and hospitals to bill Medicaid, a third-party insurance, for services and that boosts budgets at the local level. (In a climate where Congress is unlike to spend more money on Indian health.) How big a number? More than a million American Indians and Alaska Natives are now insured by Medicaid. The Kaiser Family Foundation estimated in 2013 that Indian health facilities collected $943 million in third-party payments. “By far the largest third-party payer is Medicaid, which accounts for $683 million or 70% of total third party revenues, and 13% of total IHS program funding for FY2013,” Kaiser reported. Nearly 150,000 Alaska Natives and American Indians receive health services across the state from tribal and non-profit health organizations funded by the Indian Health Service. By law the IHS-funded clinics must seek third party billing from patients, such as Medicaid, the Veterans Administration or private, employer-based health insurance.

Medicaid is an odd program for Indian Country. Most of us understand the Indian Health Service to be the government’s fulfillment of its treaty obligations. However the IHS has never been fully funded. Medicaid, however, is an unlimited check. If a person is eligible, then the money is there. Yet states, not tribes nor the federal government, determine the rules for Medicaid. And many Republican states have been determined to fight the Affordable Care Act, or Obamacare, at every turn, and that means refusing to accept Medicaid expansion (the Supreme Court ruled in 2012 that states could turn it down).

Alaska’s decision means that the number of states rejecting Medicaid is continuing to shrink. Most recently Montana agreed to expand Medicaid in April. The states with large American Indian and Alaska Native populations that have not expanded Medicaid include Oklahoma, South Dakota, Wisconsin, North Carolina, Maine, Wyoming, and Idaho. Utah is the next state considering an expansion.

The Affordable Care Act continues to evolve — and improve. But more important, steps that states are taking to expand Medicaid are adding real dollars to the Indian health system.

Mark Trahant is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.