Medicaid is not one program (again)

There is a lot that could be said about Rick Martinez’s column in this morning’s Raleigh, NC News and Observer, but I want to focus on one point: Medicaid is not a monolithic program. Instead, it covers kids, pregnant women, elderly persons living in Nursing Homes who are also poor, and the long term disabled.

Says Martinez:

Medicaid mismanagement has very real consequences for you and me. North Carolina has the highest annual Medicaid delivery cost, $6,098 per patient, in its eight-state region. Georgia delivers Medicaid at a cost of $3,979 per patient. The national average is $5,535. It simply doesn’t make sense to expand Medicaid in North Carolina under Obamacare until these fundamental problems are corrected.

You can calculate a per patient spending amount but it does not mean that much because the needs of the different types of persons covered by Medicaid differ so much. And differential coverage decisions by states (states have choices about how far up the poverty scale to cover persons today) make a simple per capita comparison dubious. Here is a Kaiser Family Foundation comparison of North Carolina’s per patient expenditure amount versus the nation as a whole (I reproduced the table that is at this link, 7th table down, below):

The only meaningful comparison across states is aged v. aged, children v. children, etc. I am not going to go and dig this up for the comparison states used in the N.C. Auditors report. For the national comparison we have lower per capita Medicaid expenditures for dual eligibles (Aged), and higher for the disabled, adults and children.

The Medicaid expansion that is available to North Carolina under financially advantageous terms would mostly expand coverage to adults, particularly men who are single (who can never qualify for Medicaid, regardless of how low their income may be, under current rules).

My point is that please, please, please, if we as a State are going to talk about Medicaid, lets get straight that it is not one monolithic program. The issues facing each group are not the same. And we can address inefficiencies in one part (or all parts) of the program while expanding coverage, quite easily. The people who are saying they are against the Medicaid expansion because of inefficiencies were against the expansion before that. Just own it.

update: revised for clarity