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Reauthorization and Beyond: The Medicaid Expansion Must Continue – posted 3/8/2015 and published in the Concord Monitor on 3/15/2015
When the New Hampshire Legislature passed the Medicaid expansion in 2014, there was one noteworthy wrinkle. The very creative Medicaid expansion plan had a sunset provision which meant it must be reauthorized by our new Legislature.That reauthorization, as part of the general budget discussion, is under review by legislators now.
Let’s be clear about what the Medicaid expansion has done. It uses available federal funds to offer health coverage to lower-income adults up to 138 percent of the federal poverty level. So far it has attracted 36,404 new recipients to the Medicaid rolls in New Hampshire. It is expected an additional 25,000 will enroll over the next six years, assuming the Medicaid expansion is reauthorized.
Overwhelmingly, the new enrollees are from low income working families. These are exactly the people who had been uninsured prior to the legislation because they could not afford the cost of health insurance. That lack of affordability is the major reason why so many do not have insurance.
New Hampshire must now consider whether the program will continue or whether it will throw thousands off the insurance they have newly obtained. Early program results have been promising. The New Hampshire Hospital Association just released a study showing that in 2014 there was a 17% reduction in the number of emergency room patients without insurance compared to 2013.
Failure to reauthorize would be the kiss of death for health insurance for these many thousands of newly insured. It is hard to estimate the damage if the Medicaid expansion goes away but I think it would be huge.
Realistically, there is no likelihood a Republican-led legislature would be crafting any alternative health insurance plan in 2015-2016 to insure low and moderate income New Hampshire citizens. Based on the available evidence, snow is more likely in July.
One oddity of the national debate around Medicaid expansion has been the emergence of the perspective that it is fine to be uninsured. Former Texas Governor Rick Perry has best articulated this position. With 22% of its residents uninsured, Texas holds the brutal distinction of having the highest rate of uninsured people in the country. In February, Republican presidential candidate Perry, on a campaign swing in New Hampshire, was quoted, saying:
“Texas has been criticized for having a large number of uninsured. But that’s what Texans wanted. They did not want a large government program forcing everyone to purchase insurance.”
I could be wrong but I do not believe any other major politician has spoken up for the alleged value of being uninsured. Perry is the first to brag about it like it is a golden badge to wear proudly. In Texas, Perry and his brand of extreme conservatives have denied 1.5 million low income people the chance to be insured. This is the estimated number of low income people in Texas who would benefit from a Medicaid expansion.
Only in the United States is there a serious debate about the value of insurance coverage for protecting health. That debate has been long settled in all other advanced industrial countries. All recognize the importance of being insured. Not to recognize that is almost the equivalent of being a flat earther.
So how is it that some have come to devalue having health insurance? Cynically, I think many of those who do the devaluing have plenty of money and they have good health insurance. Like Rick Perry, they advocate no health insurance for others.
I expect these liberty lovers who tout the freedom to be uninsured have never had a personal health crisis where they faced the future with no insurance or inadequate insurance. If they had had that kind of personal experience and they still believed in this “freedom”, you would have to wonder if there was a screw loose.
I had my own personal wake-up call and increased awareness about the importance of health insurance when I was 42. After going on a long, freezing winter hike, I came home and realized there was a slight swelling under my left arm. The next day I went over to New London Hospital to see my primary care physician. I do remember the look on his face when he examined me. He was as white as a sheet and he said I needed to see a surgeon for a biopsy.
I arranged for that, had it done at New London Hospital and then waited two weeks for the results. The verdict: malignant melanoma. Probably like many relatively young patients, I went through shock and disbelief. I was healthy. How could that person in the medical records be me?
Then I had to figure out what to do next. It was not that easy. Different doctors suggested different treatment. I went to see a radiation oncologist at Dartmouth Hitchcock Medical Center. He suggested radiation. Then I went to Brigham and Women’s Hospital in Boston to see a surgical oncologist. He suggested surgery. It was hard not to notice that doctors were businessmen who wanted business.
I did my own research and decided on surgery as the most effective treatment. I had been very impressed by the surgical oncologist I saw.
Meanwhile, the medical bills started cascading in. They were extremely confusing and I had insurance. It was honestly hard to tell how much you owed. I felt like I needed an interpreter to understand the bills. I was left with the impression that a cash register starts ringing the second you enter medical facilities and it keeps going while you are there.
I did end up having surgery which was successful. (I am still here.) The insurer required a Massachusetts pay rate when my insurance was New Hampshire-based. Even after my insurer paid, I still owed a sizable balance. I talked to my oncologist and asked him if he would accept the New Hampshire pay rate as payment in full. He very graciously agreed and waived the cost difference between state plans. Still, there were a raft of other bills that flooded in. It took me a while to resolve everything.
I had insurance and I can only imagine the outcome if I had no insurance. I probably would not have been able to see that fine oncologist. I am not sure I would have ever gotten out from under the avalanche of medical bills. It would have meant a financial burial.
There is a significant body of social science research about the costs of being uninsured. Maybe it is stating the obvious but when people lack health insurance, they are much less likely to go to the doctor when they have a medical issue because they cannot afford the treatment. They must pay out of pocket and that is a big disincentive. Medical expenses compete against other necessities requiring payment.
Lack of health insurance has led to thousands of avoidable deaths, poorly managed conditions, and undetected or untreated cancers. Lacking insurance is generally recognized as the sixth leading cause of death for people ages 25 to 64 behind cancer, heart disease, injuries, suicides and cerebrovascular disease.
I have not touched on the financial benefits to our state of having the Medicaid expansion. It has brought hundreds of millions of dollars into the New Hampshire economy. For the enrollees, they can spend their money on other needs. They do not have to worry about paying medical bills that were previously unaffordable. More generally, for the state and for local government, there is a significant cost-saving. These folks will not be downshifting medical costs onto city and town welfare.
Legislators need to find a way to get the reauthorization done. Even if only looked at from an economic angle, there is too much money on the table to pass up. By any rational cost benefit analysis, the cost to the state is very small compared to the benefits gained.
I do think the narrative of this story is very American. It is about inclusion and consideration for the health and well-being of more New Hampshire citizens.
Medicaid Expansion in New Hampshire: Acknowledging an Important Victory – posted 3/30/2014 and published in the Concord Monitor 4/6/2014
This piece appeared in the Concord Monitor on April 6, 2014 under the title “Impressive Political Maturity from Medicaid Expansion Activists”. Jon
The passage of the bill which expands Medicaid coverage to low-income citizens in New Hampshire is a historic accomplishment. Governor Maggie Hassan signed the bill on March 27 and the program becomes available for most people on July 1.
The Medicaid expansion will cover 50,000 poor New Hampshire residents who previously had no insurance coverage. Up til now, Medicaid had gaps in coverage for adults because eligibility was restricted to specific categories. If you were a single parent with dependent children, an adult with disabilities or a poor elderly person, you possibly could qualify. Now all adults earning up to 138 percent of the federal poverty limit should be able to qualify. That translates into coverage for a single adult who is earning up to $15,856. The income limit rises based on family size.
There are many costs to being uninsured. Without insurance, people needing care often avoid it. Because people wait on getting medical care, chronic medical problems become acute, Medical bills become a disincentive to going to the doctor. In the worst cases, medical debt leads to bankruptcy, major depression and suicidal ideation. Medical providers have needed to raise rates on insured people to deal with the large numbers of uninsured so there is a big economic ripple effect. The Medicaid expansion will help to break this vicious cycle since those previously uninsured will now be paying through Medicaid.
Advocates deserve much credit for building a winning coalition around the Medicaid expansion. The political maturity of this effort was impressive. The coalition included, among others, business leaders, health care providers, seniors’ organizations and a wide array of advocates reflecting different interest groups.
Instead of posturing and making impossibly purist demands, advocates used creativity in adjusting a plan specific to New Hampshire. Under the bi-partisan bill, low-wage workers will be able to use federal Medicaid dollars to buy private health insurance. This is a bit unorthodox and requires a waiver from the federal government but it allowed moderate Republicans to jump on board.
Since the New Hampshire Senate is controlled by Republicans, getting the majority in the Senate to support the Medicaid expansion was no easy task. This is particularly true because many on the right have built their 2014 political platform on opposition to Obamacare. The Medicaid expansion is an essential element of Obamacare.
I do think there is much to learn from the success of advocates in this effort. As a long-time progressive and a reader particularly of the progressive and left-wing blogosphere, I am used to seeing the glass half empty perspective. Obamacare is not single payer national health insurance. So many gnash their teeth and bemoan that.
From my past experience, many of the bemoaners are removed from the legislative process. It is easy to rail from the sidelines when you are not in the game. In my earlier life when I previously worked as a legal aid lobbyist, I was always impressed by the persistence and determination of my typically more conservative opponents. Many of the business lobbyists practically seemed to live at the legislature 24/7. That was in stark contrast to progressives who were often MIA. I used to think my side could learn from the conservative forces who did not give up and go cry in their beer. You could always count on the conservatives to be there even when they were losing.
I think you can see the Medicaid expansion from the glass half full perspective. True, everyone is not covered but this is the biggest advance I have seen in many a moon. I think the reform sets the stage for further advances toward universal coverage.
I am hopeful that the New Hampshire example can influence other states to follow our lead. When the U.S. Supreme Court ruled in June 2012 and affirmed the constitutionality of the Affordable Care Act, the Court gave states an option of expanding Medicaid. With New Hampshire as the newest addition, 26 states have now signed on with the expansion.
However, that leaves 24 other states who have not opted for the Medicaid expansion. Six of the states, including Maine, are currently considering it. The New Hampshire example may offer a way forward for those states on the fence or currently balking.
An irony of the Medicaid expansion is that the states who are refusing expansion would benefit the most from it. The states include all the southern states as well as some heartland and Rocky Mountain states. We are talking five million poor uninsured adults who will lack coverage because their state did not opt for Medicaid expansion.
There is a gap in coverage between current Medicaid eligibility and the lower limit of those Obamacare recipients who would get subsidized insurance through the federal marketplace. Just to be more specific, of the five million people who live in states that have not opted to expand Medicaid, about 20% of that group reside in Texas, 16% in Florida, 8% in Georgia, and 7% in North Carolina.
A recent Gallup poll shows that the Southern states are where residents are struggling the most to afford health care. I guess the other side of Southern hospitality toward strangers is meanness toward your own citizens. You can be sure that the governors and legislators in the south who are blocking this advance have fine medical insurance coverage for themselves.
The Medicaid expansion will inject hundreds of millions of dollars in federal funds into New Hampshire’s economy. The federal Medicaid money will allow low wage workers to spend money on other critical needs like housing, food and utilities. This should be a direct benefit for local businesses.
As more states like New Hampshire enact the Medicaid expansion, I think it will put more pressure on the states who had initially opted out to reverse course. Their citizens will see the benefit and will want it for themselves. The course of change is usually not a straight shot . It is more circuitous and Medicaid expansion is no exception.
Jonathan P. Baird 