Political Decisions with Deadly Consequences

by Fred Kammer, SJ

The Affordable Care Act (ACA) had three major provisions to promote expanded health coverage to Americans: a mandate for employers with fifty or more full-time employees to provide health insurance; an individual mandate to purchase insurance (with federal subsidies to assist families with incomes below 400% of the federal poverty level); and expansion of Medicaid coverage to all individuals with incomes at or below 138% of the federal poverty level.  (138% of the federal poverty line is now $16,105 per year for an individual or $27,310 for a family of three.) In addition, the ACA created on line markets (“exchanges”) to promote insurance competition, prevented exclusion of people from coverage for pre-existing conditions, eliminated annual or lifetime dollar limits on insurance benefits, and allowed young adults to remain on their parents’ plans until 26 years old.

            In June, 2012, the U.S. Supreme Court broke with decades of Medicaid law and provided that the Medicaid expansion was optional for the states.  Since then, 26 states and the District of Columbia have chosen to implement the Medicaid Expansion, with the federal government absorbing 100% of the cost for the first three years.  The federal share declines to, and remains at, 90% by the year 2021. Participating states must assume the balance. 

            24 states have refused the expansion, although a few are reconsidering that decision.  Without such a change in state policy, “5.7 million people will be deprived of health insurance coverage in 2016.”[1]  Almost half—2,721,000—reside in the five Gulf South states: Alabama (235,000), Florida (848,000), Louisiana (265,000), Mississippi (165,000) and Texas (1,208,000).   These are among the poorest states with the highest levels of poverty and the greatest health care needs.       

The decision not to expand Medicaid is clearly partisan—the states involved are led by Republican governors or have Republican-majority legislatures. Their repeated opposition to “Obamacare” drives this decision to reject Medicaid coverage for persons with low-incomes, although leaders offer a variety of arguments including costs to states, doubts about the permanence of the 90% federal share after 2021, the limitations of Medicaid coverage, and/or low reimbursement levels to health professionals.

            These decisions, however, have human consequences, including health problems, financial crises, and deaths among those who would be eligible for Medicaid but are not being covered.  Several studies[2] spell out the practical impact: lack of access to cholesterol-level screening, mammograms, and pap smears; no regular clinic care and physician visits; increase in people experiencing depression; and reduction in those reporting good, very good, and excellent health.  In addition, the same studies indicate that failure to expand Medicaid will result annually in 255,000 people nationwide (121,000 in the Gulf South) experiencing “catastrophic” out-of-pocket health costs (more than 30% of income) and 809,400 (386,600 in the Gulf South) having to borrow to pay medical bills or skipping other payments, such as rent or mortgage, due to medical costs. 

            Finally, one estimate is that deaths per year caused by failure to expand Medicaid range from a high of 17,104 to a low of 7,115—in the Gulf South from 6,703 to 3,603 deaths.[3]

[1] The Council of Economic Advisers, Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid, July 2014.

[2] The Council of Economic Advisers, Ibid.; Dickman, Himmelstein, McCormick, and Woodhandler, "Opting Out of Medicaid Expansion," Health Affairs, January 30, 2014; Kaiser Family Foundation, Visualizing Health Policy: Understanding the Effect of Medicaid Expansion Decisions in the South; Sommers, Baicker, and Epstein, "Mortality and Access to Care among Adults after State Medicaid Expansion," The New England Journal of Medicine, July 25, 2012. 

[3] Dickman et al, op. cit.