Ex­pan­sion of Med­i­caid of­fers ben­e­fits far be­yond im­prov­ing ac­cess to care

Modern Healthcare - - COMMENT - Dr. Ge­orges Ben­jamin

Fifty years ago this week, Pres­i­dent Lyn­don B. John­son signed into law the So­cial Se­cu­rity Act of 1965 es­tab­lish­ing the Medi­care and Med­i­caid pro­grams.

Much has been writ­ten about the fu­ture of Medi­care; but Med­i­caid, now our na­tion’s largest public in­sur­ance pro­gram, has re­cently be­come a light­ning rod for de­bate.

Orig­i­nally de­signed as a vol­un­tary so­cial in­sur­ance pro­gram for low­in­come fam­i­lies with de­pen­dent chil­dren and dis­abled Amer­i­cans, Med­i­caid now cov­ers over 70 mil­lion peo­ple and is the crit­i­cal com­po­nent of our na­tional healthcare and long-term-care safety net. Along the way it has also be­come a lab­o­ra­tory for in­no­va­tion; its flex­i­ble fed­eral-state part­ner­ship has al­lowed states to tai­lor the pro­gram to their res­i­dents, us­ing emerg­ing mod­els of care de­liv­ery to im­prove qual­ity of care and man­age costs.

History shows that the vol­un­tary na­ture of the pro­gram re­sulted in a 17year wait for full na­tional im­ple­men­ta­tion. Even then it was done in a very un­even man­ner. For some, ac­cess to ben­e­fits from the pro­gram was at best il­lu­sion­ary be­cause of the ex­tremely low el­i­gi­bil­ity lev­els and the de­gree of bu­reau­cracy re­quired by some states for both en­try into the pro­gram and main­te­nance of el­i­gi­bil­ity.

The Af­ford­able Care Act al­tered the par­a­digm and fun­da­men­tally changed the pro­gram’s po­ten­tial. Un­der the law, Med­i­caid has be­come much more ro­bust and brought us closer to the goal of pro­vid­ing na­tion­wide cov­er­age to all low-in­come peo­ple up to 138% of the fed­eral poverty level. This is true de­spite a 2012 U.S. Supreme Court rul­ing that al­lowed for states to opt out of ex­pand­ing their Med­i­caid pro­grams.

Med­i­caid ex­pan­sion un­der the ACA has un­ques­tion­ably worked in im­prov­ing ac­cess to care and im­prov­ing qual­ity. Nearly 14 mil­lion more peo­ple have gained ac­cess to Med­i­caid or the Chil­dren’s Health In­sur­ance Pro­gram since the re­form law took ef­fect. Med­i­caid now serves one­fifth of the en­tire U.S. pop­u­la­tion, which now also in­cludes se­niors, preg­nant women and a sig­nif­i­cantly greater per­cent­age of dis­abled and pre­vi­ously ex­cluded low-in­come peo­ple. De­spite this suc­cess, many Amer­i­cans still lack health cov­er­age and too many states aren’t ac­cept­ing the law’s Med­i­caid ex­pan­sion. As a re­sult, more than 7 mil­lion peo­ple re­main un­cov­ered.

The 21 states that still have cho­sen not to ex­pand the Med­i­caid pro­gram are, how­ever, fac­ing sev­eral re­al­i­ties that should re­sult in the pro­gram’s even­tual ex­pan­sion: the health needs of their cit­i­zens, the chang­ing eco­nom­ics of the health sys­tem and the evolv­ing po­lit­i­cal en­vi­ron­ment.

First, the states that have not ex­panded the Med­i­caid pro­gram are al­ready fac­ing ex­tra­or­di­nary health chal­lenges. Thir­teen rank in the bot­tom half of states as mea­sured by Amer­ica’s Health Rank­ings. A re­cent re­search let­ter pub­lished in JAMA In­ter­nal Medicine doc­u­mented that el­i­gi­ble in­di­vid­u­als in these non­ex­pan­sion states had poorer states of health in the five lead­ing causes of death (heart dis­ease, stroke, can­cer, di­a­betes and em­phy­sema), and had both the in­creased like­li­hood of re­ceiv­ing care in an emer­gency depart­ment or had their care de­layed or avoided be­cause of costs. All are ac­cess is­sues the ACA pro­vi­sions are de­signed to ad­dress.

Sec­ond, costs for Med­i­caid ex­pan­sion are mostly borne by the fed­eral gov­ern­ment. With ris­ing costs for the unin­sured in these states and the law’s re­duc­tion of dis­pro­por­tion­ate-share dol­lars paid to healthcare providers, states will even­tu­ally fa­vor pro­gram ex­pan­sion.

Ex­pand­ing Med­i­caid has other eco­nomic ben­e­fits de­spite the false ar­gu­ments posed by pro­gram crit­ics. One such anal­y­sis by Fitch Rat­ings shows 30% faster job growth in healthcare jobs in ex­pan­sion states.

Fi­nally, like all things po­lit­i­cal, public sen­ti­ment changes over time and can drive the po­lit­i­cal process. Gallup polling shows that Med­i­caid has be­come in­creas­ingly pop­u­lar among ben­e­fi­cia­ries, a fac­tor that will prob­a­bly grow as more peo­ple be­come cov­ered. In ad­di­tion, a new waiver au­thor­ity from Sec­tion 1332 of the ACA will be­come avail­able in 2017, right af­ter the next elec­tion. This lit­tle-known op­tion will give states great flex­i­bil­ity to de­velop mech­a­nisms that fur­ther ex­pand cov­er­age and craft pop­u­la­tion health mod­els to ad­dress com­plex so­cial needs. Op­po­nents of the cur­rent Med­i­caid pro­gram may find that Sec­tion 1332 af­fords them the flex­i­bil­ity and po­lit­i­cal cover to de­sign and im­ple­ment Med­i­caid ex­pan­sions.

As we honor Med­i­caid’s past we look for­ward to its fu­ture—one of con­tin­ued in­no­va­tion and suc­cess in im­prov­ing the na­tion’s health.

Dr. Ge­orges Ben­jamin is ex­ec­u­tive di­rec­tor of the Amer­i­can Public Health As­so­ci­a­tion.

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