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Expanding Medicaid is the right thing to do for public health

From the November/December ACP Internist, copyright © 2012 by the American College of Physicians

By David L. Bronson, MD, FACP

Now that the Supreme Court has ruled on the Affordable Care Act (ACA), and the election results will soon be available, it’s time to make health care reform work for the American people. I am asking that members and chapters act to support Medicaid expansion in their states.

Under the ACA, 17 million people with incomes up to 133% of the federal poverty level are eligible for Medicaid coverage, but only if the states agree to participate in the bill’s Medicaid expansion provisions. Virtually all of the cost of this expansion is borne by the federal government until 2020, when it will begin to cover 90%. Additionally, 15 million uninsured Americans will soon be covered by private plans through the ACA’s health exchange provisions.

These steps will help us achieve a major goal of the College’s advocacy effort, ensuring access to health insurance for all Americans. But many critics of the ACA are concerned that expansion of Medicaid will be a further strain on state budgets.

Because of these concerns, as well as philosophic concerns about expanding government’s role in health care, some state governors are indicating that they are unlikely to pursue Medicaid expansion. I believe that is wrong medically, economically and morally.

First, let me address the medical argument. In a study published in the Sept. 13, 2012 New England Journal of Medicine, ACP Member Benjamin Sommers, MD, PhD, and his colleagues at the Harvard School of Public Health provided the strongest evidence yet that expanding Medicaid has major positive effects on people’s health.

The study tracks data from several states that expanded Medicaid’s traditional coverage of low-income children, parents, pregnant women and disabled persons to include childless adults. This is the group of patients targeted by the ACA.

The study found that the expanded Medicaid programs in three states, Arizona, Maine and New York, were associated with a 6.1% reduction in mortality when compared to neighboring states that did not expand Medicaid. This amounts to 2,840 deaths prevented each year for every 500,000 people with Medicaid coverage. The reductions in death rates were greatest for older adults, nonwhite patients and those living in poor areas. These groups generally have the greatest barriers to care and higher mortality rates.

The next piece of evidence for expanding states’ roles in Medicaid comes from Oregon. In 2008, the state conducted a lottery for the uninsured to see who would be added to a limited number of new Medicaid policies. Ninety thousand Oregonians competed for 10,000 applications. (More information on the lottery is available online.)

Researchers followed those newly insured by Medicaid for one year and compared them to those who remained uninsured. Those who gained Medicaid coverage had improved physical, psychological and financial health; lower out-of-pocket medical expenditures; and lower rates of depression. They also used more preventive services.

Regarding the economic argument, an expanded Medicaid program will have only a small impact on state budgets because the vast majority of the funding will come from federal sources.

The Congressional Budget Office estimates that the federal government will bear nearly 93% of the costs of Medicaid expansion over the first nine years. The additional costs to the states represent a 2.8% increase in what they would have spent on Medicaid over the nine-year period in the absence of health reform. This expenditure level does not include the savings that state and local governments will realize in other health care spending for the uninsured.

The Urban Institute has estimated that overall state savings will be between $26 billion and $52 billion between 2014 and 2019. The highly respected health care policy firm The Lewin Group has estimated that state and local governments will save $101 billion in the costs of uncompensated care.

Additionally, Medicaid coverage will help support physician practices that have traditionally cared for the uninsured, as well as hospitals, particularly those in rural areas that are struggling to meet their budgets. As federal disproportionate share funds to hospitals are being cut, failure to support Medicaid expansion will force some hospitals to close.

Finally, expanding Medicaid is morally the right thing to do. The ACA provides for expanded health insurance coverage to the middle class through insurance exchanges, but it would be unconscionable to leave 17 million of the poorest Americans without coverage.

Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” We need to put our patients first, and bring the currently uninsured poor into a system of care that provides comprehensive coverage. If we don’t do it now, there will not be another chance for a generation.

I’m asking members to act. Act individually, act as an ACP chapter, or act as part of a medical staff, but act to support state expansion of Medicaid. Call your legislators, and talk with your patients so they understand that this is good for the health of the country and vital to the health of many Americans.

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