Midsummer 2012 the supreme court upheld the majority of the provisions of the ACA, and people like me who had made every major life decision since turning 22 based on where I could get health insurance (hello preexisting conditions) breathed a deep sigh of relief, wept one tear, and took a long nap.

Fast-forward to now and the part of the decision that made it optional for states to decline to expand their Medicaid programs is taking it’s toll. In states where Medicaid was not expanded, the majority of adults making under 100% of the federal poverty level have no options for health insurance. They do not qualify for the incentives available through health insurance exchanges. They cannot afford private coverage. Unethical.

Just for fun, here’s the states by political party in 2013 (source):

governors 2012

Uninsured people will still use emergency departments and be inpatients, putting hospitals in a tough position as part of the ACA takes away the pre-ACA measure of DSH (disproportionate share hospital) funding (federal dollars) that hospitals needed to account for the absence of reimbursement from these uninsured folks. DSH dollars were supposed to be replaced by payments from Medicaid insurance dollars. In states that did not expand Medicaid, DSH dollars are being replaced by zero dollars. IMHO this is on the state–but Obamacare takes the knock. From the patients denied access to affordable care, the hospitals that are in dire straights financially, and the communities that are losing their hospitals (and often largest employers) as they just can’t stay afloat.

I’m working up posts describing how one qualifies for Medicaid in non-expanded states, the state incentives offered by Medicaid expansion, and the burden on local communities with large numbers of uninsured people in poverty. This is a mire, but I can’t think of one more worthwhile to wade through. PARTY TIME!

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2 thoughts on “Falling into the gap.

  1. Melissa, in my short time practicing as an “almost nurse” in rural Virginia, I have been stunned by the reality of the lack of Medicaid expansion in the Commonwealth and the outrageous costs (still compounding on the system in the form of unpaid bills because if you’re too poor to afford insurance, chances are you’re also not able to shell out the $861 cost of just one night in the hospital as a boarder at our local community hospital).

    I think, however, it’s worthwhile to consider the why behind certain states declining expansion. A great contributing factor, as you imply in your post, is political. The red states and the yellow states line up nearly perfectly. However, it’s also worth pointing out that these states have a deep mistrust about what shape their Medicaid systems will be in when the DSH funding dries out in a decade (the federal government only intends to provide that gap funding for ten years).

    I’m in no way defending obstructionist governors nor their politicking state chambers, but I do wonder what is to become of Medicaid in the states where expansion occurred when the federal funding picture changes. Seems like self-sustaining goals might be based on “fuzzy math.”

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    1. Chandra, this is an excellent point. I understand the mistrust of the federal gov’t promises, the concern over how the feds will be able to support such a massively expensive program in light of the nation’s wee bit of debt problem, and the fear that the states are going to be left holding the bag. I got really into the weeds looking for sources showing some of the numbers estimating cost to savings state by state. They are out there but not worth posting here and as grad students we know that even the most sound study probably has something to hide.

      So the federal gov’t will cover 100% of the expansion through 2016, then decreasing to but not below 90% by 2020. If we take this at face value it is a real deal. By 2020, with a population covered by insurance and with better access to care the hope is that health care costs which for the past decade plus have been exploding will be contained, and that the 10% that the state is responsible enough will be manageable. So that is a gamble. Backed by data, but a gamble none the less.

      All said and done I believe that without the expansion we will continue, heads in the sand, hemorrhaging money all over the place. That money has got to come from somewhere. Taxpayers and patients and health care systems are certainly going suffer ever increasingly if nothing is done. If we expand Medicaid, maybe, probably, we will suffer less. I see the Medicaid expansion as a far from perfect, by no means foolproof, best option on the table (and are there any other options on the table?). There are good arguments behind small “c” conservatism, but I think the dire straits that we are in necessitate boldness. I really, really need that econ degree to back my play here. But we nurses see the human cost every day.

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