Dispute widens health divide

GOP opposition to Medicaid expansion may fuel disparities

WASHINGTON — Republican opposition in many statehouses to expanding Medicaid next year under President Barack Obama’s health care law, which could leave millions of the nation’s poorest residents without insurance coverage, is likely to widen an existing divide between the nation’s healthiest and sickest states.

With nearly every Republican-leaning state on track to reject an expansion of the government health plan for the poor, the health care law’s goal of guaranteed insurance will become a reality next year mostly in traditionally liberal and moderate states. These states already have higher rates of health coverage.

Residents of these states — concentrated in the Northeast, Upper Midwest andWest Coast — also have better access to doctors and are less likely to die from preventable illnesses.

Colon cancer deaths in states opposing Medicaid expansion, for example, are an average of 16 percent higher than in pro-expansion states, according to a Tribune Washington Bureau analysis of state health data.

Deaths from breast cancer are 8 percent higher on average in anti-expansion states. And adults younger than 65 are 40 percent more likely on average to have lost six or more teeth from decay, infection or gum disease. Medicaid by itself may not close those gaps, which also reflect income and education disparities. And conservative critics of the program, who contend it could ultimately sap state budgets, say alternative strategies would better help poor Americans, including limits on government aid to encourage people to take responsibility for their own health care.

“Government assistance should not be an entitlement. Government assistance should not be a lifestyle,” said Michigan House Speaker Jase Bolger, a Republican who has called for an overhaul of the state’s Medicaid program, including a four-year limit on benefits for non-disabled adults.

At the same time, most state leaders who are fighting theMedicaid expansion have advanced few alternative plans to tackle their states’ health shortfalls. That means that, at least in the short term, America’s unhealthiest states could fall even further behind as the Affordable Care Act is implemented.

“Many states may be missing a real opportunity to reduce some of the big differences we see across the country in health,” said Cathy Schoen, a health economist at The Commonwealth Fund, a nonprofit, who has studied the variations between states.

Medicaid, which is jointly funded by state and federal governments, requires states to cover only certain vulnerable groups, such as poor children and the disabled. Some states have expanded their programs while others have not, contributing to wide differences in health coverage.

Today, for example, about 94 percent of adults ages 19-64 in Massachusetts have health coverage— the highest rate in the nation — as a result of a mix of Medicaid and commercial insurance under a plan developed by then-Republican Gov. Mitt Romney and Democratic lawmakers.

By contrast, 68 percent of working-age Texans are insured, the lowest rate.

The national health law set out two ways to guarantee health coverage.

Americans who make more than the federal poverty level — about $11,500 a year for an individual— and can’t get coverage through their employer will be able to shop for health plans on new Internet-based markets, called exchanges. Government subsidies will be available to consumers making less than four times the poverty level.

Very poor Americans were slated to get insurance through the expansion of eligibility for Medicaid programs. But last year, that plan was upended when the U.S. Supreme Court ruled that states could elect not to go along with theMedicaid expansion.

Most GOP governors immediately ruled out expanding Medicaid and have resisted months of lobbying from doctors, hospitals and business leaders. Republican governors in Florida, Ohio, Michigan and Arizona who want to expand Medicaid are also being blocked by Republicans in state legislatures.

Many Republicans, citing Medicaid’s ballooning cost, say they are worried the federal government, slated to pick up more than 90 percent of the tab for the expansion, will renege in the future.

“You are going to have to find away to pay for (Medicaid) through taxation, or you are going to have to reduce other very important state budget items,” Arizona Senate President Andy Biggs said.

Medicaid is nowthe largest expense for most states, outpacing education. But growing evidence suggests the program has real health benefits.

Researchers found that mortality rates declined by 6 percent in Maine, New York and Arizona after they expanded Medicaid to poor adults a decade ago but were largely unchanged in neighboring states.