Why are so many states not taking the Medicaid Expansion?

[John_Stamos_Left_Ear]

@puddleglum

The thing with programs that give away money is that once they are started they are hard to do away with. For example tobacco subsidies, the government paid 188 million dollars in subsidies to farmers growing tobacco in 2012. The Senate just voted this May to keep paying the subsidies even though the same government is spending about 50 million dollars a year for ads trying to keep people from smoking.

I must admit, it would be difficult for me to give up healthcare. You might say I would die without it. :rolleyes:

Seriously, this idea amuses me. You really equate people getting life-saving health care or not having to choose between that and financial ruin with big tobacco lobbyists and their hold over the government.

At what point would you consider it reasonable for you “to do away with” your own healthcare, out of curiosity? You know, at what time would you personally decide for you and your loved ones that it was time “to do away with” the ability to get healthcare? I am curious where that line is for you. You know, since you said there’s a line and all.

So a responsible governor takes into account that a program will be hard to end and looks down the road for the consequences.

The program in question provides subsidies for people without much money. The program will not be necessary if there are no people without much money. Which party is against making a livable minimum wage again?

And at what point does a governor tell poor people that they will be unable to get healthcare anymore? Does he just say “Go be poor somewhere else?”

But I do think your reasoning is spectacular, as usual. And it does fit in with the Republican Healthcare Plan Alternative.

[Magiver]

@John_Stamos_Left_Ear

The narrative concerning states rejecting the expansion all seems to point to how Republicans at the state level are making a bad choice - they are passing up free money in times when most states can use all of the income they can get to help with their budgets.

Tell me about this free money. I’d like to subscribe to your newsletter.

[brickbacon]

@puddleglum

The average state pays 16% of its budget for Medicaid and opting into the expansion will raise costs an estimated 2.8% for the next eight years and more after that. Medicaid costs have rised over 7% a year over the last decade while state tax revenues have risen about 3.5%. Thus Medicaid is set to take up more and more of state budgets in the future. Given budget realities states need to look at ways to decrease amounts spent of Medicaid instead signing up for more spending.

You keep ignoring the fact that the state pays for all of these people indirectly anyway, and that the expansion offers a much better deal than the one they are currently taking. I get your point, but the fact is that you keep forgetting to mention the costs of inaction, and the benefits of action. People without insurance don’t just die without costing anyone else money. They miss work, costing the government tax money. They go to the ER (which often costs more than PCP visits would have cost) and rack up bills they cannot afford to pay. Those costs get passed on to paying customers via higher insurance premiums, and more direct subsidies to hospitals. Those insured people don’t get raises because their untaxed employer provided heath insurance eats up their raises. Regardless of how you feel about healthcare, foregoing an ounce of prevention has real costs even if the government can figure out ways to ensure they are not directly reflected on their books.

The point should be whether it’s more efficient to subsidize these people on the front end or the back end. Additionally, we need to consider that the choice as presented to these governors is more than just whether to expand medicaid since medicaid reimbursement fees and expectations will be affected regardless of how they act.

[John_Stamos_Left_Ear]

@Magiver

Tell me about this free money. I’d like to subscribe to your newsletter.

sigh

I think you know that my using the term “free” was a shorthand way of saying “at no cost to the state.” Which is the case for the first three years.

[John_Stamos_Left_Ear]

@brickbacon

The point should be whether it’s more efficient to subsidize these people on the front end or the back end.

And this one should be obvious… What person do you think costs more:

Person A: Has had healthcare insurance subsidized to some degree by someone or by a combination of several sources. This person has had preventative care at no or very little cost to him for as long as he has been insured which is great for keeping healthy and catching conditions earlier when they are easier and cheaper to deal with. This person can fill prescriptions with a reasonable out-of-pocket co-pay. If this person gets an illness or has a minor accident, they have a myriad of options on how to handle it.

Person B: Does not have any healthcare insurance. This person is considerably less likely to regularly get check-ups because they cost him money. Without basic preventative care, it is more likely that conditions which require medical attention will not be addressed until they are farther along which makes it more likely to cost more to treat. If prescribed a medication, if it costs too much to fill he may very well just try and do without it, maybe for a month or maybe entirely. If this person gets an illness or has a minor accident, he probably chooses to go to an emergency room to be treated, even though it’s by far the most costly way to get treatment.

I think it’s obvious that while both people might be a drain on the system, Person A will be far less costly.

The only way to change this is to remove the laws that state that Emergency Rooms have to treat people regardless of their ability to pay. Which doesn’t seem like it will be a popular option (and I don’t think it has been seriously brought up by anyone) even though during the last Republican primary, a Tea Party debate audience famously cheered the idea of letting uninsured patients die.

[Magiver]

@John_Stamos_Left_Ear

sigh

I think you know that my using the term “free” was a shorthand way of saying “at no cost to the state.” Which is the case for the first three years.

So, no cost to the state, that was my error? Free money for 3 years. Then what? Do the states have to pay it back? Any interest involved?

[John_Stamos_Left_Ear]

@Magiver

So, no cost to the state, that was my error? Free money for 3 years. Then what? Do the states have to pay it back? Any interest involved?

Sorry, I thought you were being snarky given my imperfect choice of words.

After that, Federal support will then phase down slightly over the following several years (95 percent in 2017, 94 percent in 2018, and 93 percent in 2019). By 2020 and for all subsequent years, the federal government will pay 90 percent of the costs of covering these individuals. This is considerably less than they are paying for Medicaid unexpanded. According to brickbacon in this thread, they only get reimbursed by the federal government 57% of costs on average which sounds about right (I am sure he can dig up a cite if he is so inclined.)

Here’s what the non-partisan Congressional Budget Office has to say about the costs:

Claims that states will bear a substantial share of the costs of expanding Medicaid, however, and that the expansion would drain state budgets do not hold up under scrutiny.

The Congressional Budget Office (CBO) estimates that the Medicaid expansion will add very little to what states would have spent on Medicaid without health reform, while providing health coverage to 17 million more low-income adults and children. In addition, the Medicaid expansion will reduce state and local government costs for uncompensated care and other services they provide to the uninsured, which will offset at least some — and in a number of states, possibly all or more than all — of the modest increase in state Medicaid costs. Expanding Medicaid is thus a very favorable financial deal for states.

CBO estimates show that the federal government will bear nearly 93 percent of the costs of the Medicaid expansion over its first nine years (2014-2022).

Other independent analyses show similar or even more favorable results for states. An Urban Institute analysis finds that state Medicaid expenditures would likely increase by 1.4 percent over what states would otherwise spend on the program from 2014 through 2019, before taking offsetting savings in uncompensated care and other health services into account, while the Lewin Group estimates an increase in state Medicaid expenditures of 1.1 percent over that period. These estimates reflect the increased state costs for Medicaid but not the offsetting savings states will also secure in uncompensated care and other health services.

In short, the Medicaid expansion will cover 17 million low-income people at a very modest cost to states — a cost that will be at least partly offset by savings in uncompensated care and other state-funded services for the uninsured.

A state’s decision not to go ahead with the Medicaid expansion, despite this extremely favorable financing, would have adverse consequences for many poor individuals and families without health insurance.

And those are conservative numbers. When you factor in the drain put on the system by uninsured people, it’s possible that several states will actually make money on the deal.

And making money is even better than “free” money, right?

[puddleglum]

@John_Stamos_Left_Ear

And this one should be obvious… What person do you think costs more:

Person A: Has had healthcare insurance subsidized to some degree by someone or by a combination of several sources. This person has had preventative care at no or very little cost to him for as long as he has been insured which is great for keeping healthy and catching conditions earlier when they are easier and cheaper to deal with. This person can fill prescriptions with a reasonable out-of-pocket co-pay. If this person gets an illness or has a minor accident, they have a myriad of options on how to handle it.

Person B: Does not have any healthcare insurance. This person is considerably less likely to regularly get check-ups because they cost him money. Without basic preventative care, it is more likely that conditions which require medical attention will not be addressed until they are farther along which makes it more likely to cost more to treat. If prescribed a medication, if it costs too much to fill he may very well just try and do without it, maybe for a month or maybe entirely. If this person gets an illness or has a minor accident, he probably chooses to go to an emergency room to be treated, even though it’s by far the most costly way to get treatment.

I think it’s obvious that while both people might be a drain on the system, Person A will be far less costly.

The only way to change this is to remove the laws that state that Emergency Rooms have to treat people regardless of their ability to pay. Which doesn’t seem like it will be a popular option (and I don’t think it has been seriously brought up by anyone) even though during the last Republican primary, a Tea Party debate audience famously cheered the idea of letting uninsured patients die.

The correct answer is that person A will cost a significantly more amount of money. Preventative screening costs more money than it saves.

“It seems counterintuitive: If you provide care to prevent all these expensive diseases, it should save money,” said Peter Neumann, an expert on health policy and professor of medicine at Tufts University School of Medicine. “But prevention itself costs money, and some preventive measures can be very expensive, especially if you give them to a lot of people who won’t benefit.”

The idea that government provided insurance cuts visits to the ER is not true In Massachusetts ER visits went up significantly after RomneyCare passed.

…state health officials found that ER visits rose 9 percent from 2004 to 2008, to about 3 million visits a year.

Supporters of medicaid expansion are trying to make the case that they can cover more people and spend fewer dollars. This is just not the case, there is no such thing as a free lunch, even when your talking about hospital food.

There have been studies which suggest people on Medicaid die earlier than those without insurance. Since much of health care spending is done for older people this could save money. But I don’t think saving money by killing old people is good policy. I guess that means I won’t get on job on one of the death panels.

[John_Stamos_Left_Ear]

@puddleglum

The correct answer is that person A will cost a significantly more amount of money. Preventative screening costs more money than it saves.

I could get by maintaining my car far less vigorously than the manufacturer recommends. I would spend less money on maintenance that might be put off for later or even ignored completely. I would also spend far less money on fixing it if I had to junk it after something catastrophic happened.

So thanks for pointing out that it’s infinitely less expensive to care for dead people than sick people and that some preventative care might be wasteful.

The idea that government provided insurance cuts visits to the ER is not true In Massachusetts ER visits went up significantly after RomneyCare passed.

Or maybe it just took a couple of years for that trend to develop:

(A) just-released analysis, by the Blue Cross Blue Shield of Massachusetts Foundation found, for the first time, that ER visits (among non-elderly adults) have started to drop. Here, according to the report, which is also published in the current issue of the journal Health Affairs are the numbers:

*Between fall 2006 and fall 2010, there were reductions in emergency department use overall (down 3.8 percentage points), frequent emergency department visits (down 1.9 percentage points), and the use of the emergency department for non-emergency conditions (down 3.8 percentage points). This is the first reduction in emergency department use among nonelderly adults in Massachusetts observed in the MHRS.

The reduced reliance on the emergency department among nonelderly adults may reflect many factors, including the increases in use of other types of health care (e.g., increases in preventive care visits, multiple doctor visits, specialist visits, and dental care) or increases in cost sharing under their health plans.*

WBUR (1/26/2012)

I think it’s nice that you ignore the fact that people are dying because of this.

“We found that 45,000 Americans are dying annually, due to lack of health insurance,” said Dr. Steffie Woolhandler.

Woolhandler was part of a team that tracked more than 9,000 people for up to 13 years, comparing the health of those with insurance to those without. After factoring in education and income, smoking, drinking and obesity, researchers found that the uninsured had about a 40 percent higher risk of death, linking 45,000 American deaths a year to lack of insurance. In 1993 it was 25 percent.

CBS News (9/17/2009)

And the voice of dissention to that data in the news piece is from a conservative Think-Tank that is lobbying against the ACA and, similarly, espouses Climate Change denilism.

So what price do you put on 45,000 lives? If it’s only a quarter of that, what price do you put on 11,250 lives per year?

[Fear_Itself]

@puddleglum

Supporters of medicaid expansion are trying to make the case that they can cover more people and spend fewer dollars.

No one has ever made that case. What they have claimed and what your statistics show, is the** cost per person** served, is lower.

[puddleglum]

@John_Stamos_Left_Ear

I could get by maintaining my car far less vigorously than the manufacturer recommends. I would spend less money on maintenance that might be put off for later or even ignored completely. I would also spend far less money on fixing it if I had to junk it after something catastrophic happened.

So thanks for pointing out that it’s infinitely less expensive to care for dead people than sick people and that some preventative care might be wasteful.

Or maybe it just took a couple of years for that trend to develop:

I think it’s nice that you ignore the fact that people are dying because of this.And the voice of dissention to that data in the news piece is from a conservative Think-Tank that is lobbying against the ACA and, similarly, espouses Climate Change denilism.

So what price do you put on 45,000 lives? If it’s only a quarter of that, what price do you put on 11,250 lives per year?

If screenings cost 10$ and treatment costs 100 dollars than a screening that catches something saves 90. So it saves money from the perspective of the individual who had something. But if the disease caught affects only 5% of the population then giving everyone screenings will increase the costs of the system as a whole. This is why preventative screenings don’t generally save money.
Emergency room visits are backup in Massachusetts. Overall growth in per capita healthcare spending is 15% in Mass. versus the rest of the country since Romney Care passed. pdf
The 45,000 die from uninsurance is based on a study that interviewed people one time and then those who had insurance at that time were compared with those who did not. There was no followup to see if insurance status had changed with either group. Those who lacked insurance were more likely to be poor and high school dropouts, both of these groups have much higher death rates regardless of insurance status. Hereis a study that track people across time and controls for more variables. It found no significant difference in mortality.
Generally even studies that do find a difference in mortality compare the uninsured with the privately insured. Most studies that compare those on Medicaid with the uninsured find no difference or higher mortality for those on Medicaid. I linked to two such studies in my earlier post. Since we are talking about expanding Medicaid and not private insurance those studies are more germane to the proposed expansion.

[John_Stamos_Left_Ear]

@puddleglum

If screenings cost 10$ and treatment costs 100 dollars than a screening that catches something saves 90. So it saves money from the perspective of the individual who had something. But if the disease caught affects only 5% of the population then giving everyone screenings will increase the costs of the system as a whole. This is why preventative screenings don’t generally save money.

In individual cases, it can save money. In many cases it can save lives which is the main objective.

Emergency room visits are backup in Massachusetts.

From your cite:

“There are pockets in the state of communities where’s there is a really severe shortage of providers," Dunlap said. "So that when you have insurance and you don’t have a primary care doctor you go to the emergency room.”

Seems that there’s job opportunities for Primary Care Physicians in Massachusetts. Which means that RomneyCare is creating jobs (or at least job openings).

Overall growth in per capita healthcare spending is 15% in Mass. versus the rest of the country since Romney Care passed. pdf

Massachusetts was one of the most expensive states for healthcare *before *RomneyCare. That’s one of the reasons that the state was ripe for healthcare reform:

Massachusetts has long been a high health care spending state, and the 2006 health reform law did not significantly increase the rate of growth in the state’s health insurance premiums.

Total Growth Rates by Payer Have Been Similar Since 1991 (See chart on page 10)

Massachusetts Health Reform Did Not Escalate the Trend in Health Care Cost Growth

Massachusetts health insurance premiums have long been higher than the national average. In the years after Massachusetts passed health care reform legislation in 2006, however, private premiums have actually grown more slowly than the national average. (See chart on page 12)

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS FOUNDATION (3/2012)

The 45,000 die from uninsurance is based on a study that interviewed people one time and then those who had insurance at that time were compared with those who did not. There was no followup to see if insurance status had changed with either group. Those who lacked insurance were more likely to be poor and high school dropouts, both of these groups have much higher death rates regardless of insurance status.

Actually all of those factors were taken into account:

Results: Among all participants, 3.1% (95% confidence interval [CI] = 2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI = 1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio = 1.40; 95% CI = 1.06, 1.84) than those with insurance.

Conclusions: Uninsurance is associated with mortality.

Hereis a study that track people across time and controls for more variables. It found no significant difference in mortality.

This fact sheet references several other studies (all in the footnotes) to make the following points:

One-quarter (25%) of uninsured adults go without needed care each year due to cost. Studies repeatedly demonstrate that the uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases. Research has also suggested that insurance can decrease likelihood of depression and stress.

Health providers can choose to not provide care to the uninsured. Only emergency departments are required by federal law to screen and stabilize all individuals. However, the uninsured are not necessarily more likely to use the emergency room than those with insurance. If the uninsured are unable to pay for care in full, they are often turned away when they seek follow-up care for urgent medical conditions.

The uninsured receive less preventive care and recommended screenings than the insured. Uninsured older adults (ages 50-64) were far less likely than their insured counterparts to report having been screened for cancer in the past five years.
Receiving needed care is especially important for the uninsured since they are generally not as healthy as those with private coverage. The uninsured are at higher risk for preventable hospitalizations and for missed diagnoses of serious health conditions. After a chronic condition is diagnosed, they are less likely to receive follow-up care and as a result are more likely to have their health decline. Lack of follow-up attributed to being uninsured can delay the detection of certain cancers, which can result in adverse outcomes. It follows that the uninsured also have significantly higher mortality rates than those with insurance.

The uninsured report higher rates of postponing care or forgoing needed care or prescriptions due to cost compared to those enrolled in Medicaid and other public programs. A seminal study of health insurance in Oregon found that the uninsured were less likely to receive care from a hospital or doctor than newly insured Medicaid enrollees. A follow-up study found that newly insured Medicaid enrollees were much less likely to delay care because of costs than the uninsured.

Also, it should be noted that HSR published a comprehensive rebuttal to your study and yet another study contradicts Richard Kronick’s findings:

Dorn, the Urban Institute researcher, pointed to a second study published by the Institute of Medicine on Feb. 24, 2009. This 268-page volume, America’s Uninsured Crisis: Consequences for Health and Health Care, provides a detailed analysis of subsequent studies on the topic. While it didn’t provide a new estimate of extra deaths from uninsurance, the new Institute of Medicine study concluded that “the body of evidence on the health consequences of health insurance is stronger than ever before.”

Karen Davis, the president of the Commonwealth Fund and an Institute of Medicine member, said that the existence of Kronick’s study “doesn’t convince me yet not to use the IOM study,” but she added that “if I saw a few more, I might be convinced. I tend to believe things when I see multiple studies using different databases and methodologies come to the same conclusion.” (Aaron said he agreed with Davis on this point.)

On one key point, the Institute of Medicine and Kronick actually aren’t that far apart. Kronick said he doesn’t doubt that individuals’ health suffers when they’re uninsured.

So even the author of the one credible study that contradicts several other studies still feels that those uninsured have lower qualities of care than those with insurance.

And it’s a safe bet that he’s also on board with the ACA since he is the new directorof the Agency for Healthcare Research and Quality (AHRQ), a government agency that answers to the U.S. Department of Health & Human Services.

[puddleglum]

The contention was made earlier that expanding Medicaid would save money overall by increasing preventative care since it prevents people from being sick. I made the point that preventative care does not save money but costs money and you seem to agree. Even the study you excerpt from agrees

With regard to policy implications, we agree with Kronick that the case for expanding health insurance coverage should not be based on the argument that it will pay for itself by reducing overall health spending. Other research clearly indicates that covering the uninsured will increase their health spending.

So expanding coverage is going to cost states more money.
Massachusetts is a case study in this. They had very expensive health care before, they expanded coverage which was supposed to keep costs down since emergency room visits would be replaced by doctor visits. What has happened is that costs have not been kept down but are rising faster than the rest of the country from a high starting point. So we can see whatever else expanding coverage will do there is no reason to believe it will keep costs down, but rather the opposite. Costs will continue to rise. Thus any state trying to contain health care costs should try a different approach.
Studies contradict one another and I don’t think there is a conclusive proof as to whether health insurance is the reason for decreased mortality or a marker for something else. However, even as the author of your study makes the case for more government involvement in health insurance, he takes care to not say that people on Medicaid as opposed to private insurance have better mortality outcomes, only that they seek care more often. The Oregon study he mentions has so far found no difference in health outcomes between those who signed up for expanded Medicaid and those who did not.

[John_Stamos_Left_Ear]

@puddleglum

The contention was made earlier that expanding Medicaid would save money overall by increasing preventative care since it prevents people from being sick. I made the point that preventative care does not save money but costs money and you seem to agree.

So what? Almost everyone seems to think that people are better with quality preventative care. Almost everyone seems to agree that people without insurance get far less of that than people who have it.

Then you just repeat a bunch of stuff that I already responded to with citations so I suggest you read them.

[adaher]

It’s a tradeoff. You can pay more for better preventive care, or you can pay less and save money at the cost of poorer health outcomes.

[BrokenBriton]

@puddleglum

I made the point that preventative care does not save money but costs money and you seem to agree.

This is not correct but even if it were remotely accurate, surely you grasp the lunacy of the statement in a society spending almost 60% of the planets military budget? This is Dr Strangelove territory.

Also,are you honestly saying it is better, for example, to manage the continuing obesity epidemic than to prevent obesity: Never mind the quality of life issues, you think it’s better to support people with increasing lack of mobility, diabetes, a huge range of indirect physical and psyhological issues that to prevent it in the first place?

Utterly bonkers.

[adaher]

How would you prevent obesity through the health care delivery system? I wasn’t aware that you could go to a doctor to get treated for obesity.

[BrokenBriton]

It becomes (financially) efficient for the healthcare system to prevent obesity. So the system finds ways to increase education, to curb industry practices, to better label, to keep trying to find ways to effect change, and keep on trying.

In fact, it soon becomes efficient for this to spill over to the workplace, to the school system (education meals, vending machines, etc).

Atm, as presently constituted, the US healthcare industry makes fortunes from the consequences of obesity: obesity is beautifully longterm and each sufferer a reliable cash cow.

[NotfooledbyW]

@John_Mace

Wow. That make you ebetter than other people. Or something.

Exactly. States are sovereign entities and should and be able to set up their services as the people in that state desire.

Its interstate commerce. Works just like interstate common defense. The
Feds are in both to stay. Big business likes it.

[adaher]

@BrokenBriton

It becomes (financially) efficient for the healthcare system to prevent obesity. So the system finds ways to increase education, to curb industry practices, to better label, to keep trying to find ways to effect change, and keep on trying.

In fact, it soon becomes efficient for this to spill over to the workplace, to the school system (education meals, vending machines, etc).

Atm, as presently constituted, the US healthcare industry makes fortunes from the consequences of obesity: obesity is beautifully longterm and each sufferer a reliable cash cow.

Okay, but that’s not health care spending as we understand it. It’s like calling the “Say No to Drugs” campaign part of the health care system.

For the purposes of Medicaid, “preventive services” means things like mammograms, prostate screenings, etc. Services that you get from a medical provider to try to catch a problem before it becomes an emergency. Things like anti-obesity campaigns may or may not technically come out of the nation’s health care budget, but aren’t part of Medicaid’s budget, which is just used for reimbursing providers for care.