March 28, 2013 1 Comment
My friend and Duke colleague Chris Conover has an op-ed in the News and Observer today on North Carolina’s decision to not expand Medicaid under the auspices of the ACA.
I don’t know what our state ultimately will decide about this in the years ahead. The best solution, now being worked out in states such as Arkansas and Ohio, might be one in which those on Medicaid are allowed to enroll in private health insurance on the exchange. What I do know is that the public is best-served by knowing all the facts, not just those cherry-picked by advocates on one side or the other.
My book proposed this (ch. 7, p.64-67):
End the Medicaid program by transitioning responsibility of dual eligible Medicaid costs to Medicare, while moving non-elderly low income persons into subsidized private health insurance state undertaking the Medicaid expansion, but moving over time to buy low income persons into private insurance sold on exchanges.
No one is seriously talking about federalizing the full cost of the dual eligibles now, and I will leave that argument aside for now which mostly focuses on long term care/coordination of the frail elderly. My reasoning for having a long term goal of buying low income persons private insurance in exchanges is as follows (ch 7, p. 65):
Conservatives seem to viscerally dislike Medicaid because it is a government insurance program, while Progressives believe its safety net function is vital to the well being of our country. I believe the political viability of Medicaid as currently structured is in doubt, and that budget pressures will cause incremental reforms that will chip away at the safety net provided by the program. In the current climate, Medicaid is being looked to shoulder spending cuts in an unthoughtful manner. Progressives need to drive changes to the program in order to protect vulnerable beneficiaries, and there are incentives for both Progressives and Conservatives to transition away from the current program.
The logic behind the proposed changes rests in the different needs of the “three programs” represented within Medicaid. Those covered by acute care Medicaid (45-50 million persons) most of them pregnant women and children, are relatively inexpensive to care for on a per capita basis. Increasingly, such beneficiaries have trouble finding providers who will care for them, due to a double whammy of stigma (it is insurance for persons who are poor) and the fact that it pays providers below what Medicare pays, which is less than what private insurers pay. This has lead to a systematic access problem for some Medicaid beneficiaries who have trouble finding a physician willing to treat them. There is nothing inherently wrong with the structure of Medicaid; we could decide to make it the best payer of care tomorrow, but that of course, is not going to happen. Buying them into private insurance policies will mainstream their care and remove a layer of cost shifting. [emphasis added]
A fascinating aspect of the debate is the disagreement on basic facts about the impact of Medicaid on health. Chris says (and I agree) that:
What I do know is that the public is best-served by knowing all the facts, not just those cherry-picked by advocates on one side or the other.
And he then notes that the Oregon Medicaid expansion and subsequent study is the best evidence we have about the impact of Medicaid on health, and that research finds no significant difference in mortality between those who are uninsured v. Medicaid, though other measures of health were improved by Medicaid v. being uninsured. Chris notes that based on this study, saying Medicaid definitively “saves” lives is sketchy. Of course it would also render the opposite claim–that Medicaid makes you more likely to die, just as false, as Rep. Ellmers said recently, though she was using data from a different study than the one Chris notes (and I agree) is not as rigorous. So, she was cherry picking.
So, there are dueling studies with divergent outcomes (this is a good overview of the full literature; there is a lot to read down this path; I believe that it shows fairly clearly that Medicaid is better for health than no health insurance, when taken as a whole). However, there seems to be nothing that can bridge the gap to get proponents and opponents to agree on whether expanding Medicaid is on balance good or bad for health. This puzzles me, but I think it most importantly shows that this debate is first and foremost a political disagreement, which can only be settled by a political deal.
That brings us back to North Carolina’s choices:
- Option 1: Do nothing, which is now the default based on the actions of the General Assembly and Governor
- Option 2: Expand Medicaid under the auspices of ACA
- Option 3: Undertake a “private expansion” similar to what Arkansas and other states are planning to try
Option 1 is the worst. Option 2 is far preferable to doing nothing, and it would allow our state to benefit from the experience of other states trying different models while expanding coverage now, allowing us to shift course later if we choose to do so. Option 3 would be for the General Assembly and Governor of North Carolina to come up with an innovative plan to move ahead in a different manner now, presumably based on private health insurance, using the great political leverage we would have because the Obama Administration would love to say yes. Choice 3 is also much better than doing nothing.
North Carolina, lets do something.