‘There’s an opportunity for more collaboration when the financial picture is better for everyone’

Did you foresee the U.S. Supreme Court ruling that states could opt out of expanded Medicaid eligibility under the Affordable Care Act? What are the main arguments for expansion, and the main arguments against it?

Like most health policy people, I was flabbergasted at the 2012 Supreme Court decision. I didn’t realize that the Supreme Court would make expansion optional for states.

I would say this is probably one of the most closely studied health policy issues in history. The arguments for expansion have grown over the years. At their core is something very simple: If someone is sick or hurt, or gets cancer, they should be able to go to the doctor or hospital and not worry about going bankrupt. And that’s exactly what Medicaid expansion does. It’s health coverage.

The other benefits are a healthier workforce, healthier families and more kids who get coverage.

I think arguments against expansion have narrowed over the years, especially in the face of research on the positive effects. I think those arguments boil down to one: We can’t afford it as a society, whether it’s the federal or state government [paying for it].

And two: There’s an ideological opposition [saying] the government shouldn’t be helping people who can’t get health coverage through their work.

In your role at Georgetown, you follow what’s going on with access to coverage and care nationwide. How could expanding Medicaid eligibility help rural hospitals, in particular, address the challenges they’re facing?

There are many different drivers that rural hospitals have to deal with regarding their expenses. I think hospital administrators are like farmers. I don’t think I’ve ever met a farmer who says, “I’m doing great, I have plenty of money and I’m going to be able to buy that hay baler I need.” They’re going to have problems. And we do have that situation, especially for our rural hospitals.

I collaborate with the University of North Carolina, which has a rural health research program. When you look at its map of rural hospitals that have closed in the last 10 years, you see those hospitals closing are centered in non-expansion states. Seven of them are in North Carolina. They have a lot of financial pressures on them.

So how would expansion make a difference in terms of revenue generated for these rural hospitals and the services they’re able to provide to patients?

I’ve sat down with a lot of hospital administrators in North Carolina, Kansas, a lot of nonexpansion states.

First, a lot of people coming through the door of your emergency room, especially at rural hospitals, don’t have health insurance. Medicaid expansion means that many more people walking into your hospital have health insurance, so you can treat them in the way they need to be treated and you’re going to get compensated for that time.

Second, I’ve found from talking with leaders of community health centers and hospitals that there’s an opportunity for more collaboration when the financial picture is better for everyone.

That means you’re not worrying about who’s going to take care of the uninsured or whether you’re sending them to a community health center or the emergency room. When that financial pressure is off, then those institutions can collaborate more effectively.

To date, 39 states and the District of Columbia have adopted Medicaid expansion. Of the 11 non-expansion states, which should we be watching this year?

I think North Carolina is number one. It’s a state where the Republican leadership has been very clear they would like expansion. I think there’s a lot of commitment on both sides of the aisle and from Gov. Roy Cooper (D) to move forward and make compromises. I really expect them to move forward this year.

I also think there’s going to be robust debate in Wyoming.

Some of the folks from Montana, which is an expansion state, talked with legislators in Wyoming and said, “It’s working really well, we have a lot more people insured, it’s not wasting money, and it’s a good thing.”

Alabama is another state where the governor has a lot of power to expand the program and where there’s discussion.

Over time, I think what’s happened is you see a lot less of the ideological debate and a lot more of the practicality of expansion. And so you get a lot of chambers of commerce in rural areas—which have hugely pushed for expansion, because a lot of their business members can’t afford to buy health insurance for their employees. You have a lot of towns jumping in for expansion. You have a lot of members of state legislatures who hear from their constituents: from a single mom who’s working through community college and doesn’t have a fulltime job, but would like to buy health insurance. So I think it’s become much more bipartisan over the years and North Carolina is really a leader in that.

I think if North Carolina expands, then this will have an effect on other states as well. It will be a bellwether of sorts. North Carolina is one of the four states in the union that have the most people who would benefit from expansion—those are North Carolina, Georgia, Texas and Florida—and it’s also in the South. And so these other states that are kind of teetering on the edge may look at North Carolina and say, “Wow, you know, if the Republican leadership there can do it, maybe we ought to take a second look at this.”

South Dakota voted via ballot measure to adopt Medicaid expansion in November. Are there any other states that could do so?

There are two left, and they’re both long shots: Mississippi and Florida.

Mississippi has a unique problem because its ballot measure statute was invalidated by the Mississippi Supreme Court a few years ago. So it needs to pass a new statute that meets the requirements the court laid out. There’s a lot of interest in doing that, because it’s not just Medicaid expansion— there are many other issues that people in Mississippi would like to vote on.

The second state is Florida, which has another ballot process. But it’s very difficult to get on the ballot in Florida, and it has a supermajority requirement for passage. So that means you have to have 60% of people vote for it. I do think there’s a chance there as well.

It’s much more of a long shot in both those states than it was in South Dakota. But I think it will be under discussion.

“If someone is sick or hurt, or gets cancer, they should be able to go to the doctor or hospital and not worry about going bankrupt.”

associate professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families, helped advocate for the passage and implementation of the Affordable Care Act. He discusses his predictions for Medicaid eligibility expansion and the arguments for doing so.