On Refusing to Expand Medicaid

Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…” 1 Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why.

Please understand that refusal to expand Medicaid is not about state expenditures. Over the ten years, 2013-2022, every state would gain far more than it would spend for expansion.2 Were all states to opt-in, the total ROI for the states combined would be almost 10,000% ($8 billion state expenditures in return for $800 billion federal).

Empirically health is associated with income, so if you’re poor you’ll likely have worse health. Also it’s well known that chronic conditions are often comorbid, that if you have a chronic disease, you probably have more than one. Additionally, chronic disease is a major contributor to total health care costs. Here’s a graph of percentages of two chronic diseases, coronary heart disease and diabetes, across the 50 states.

MedaidChronicAggregated at the state level there’s a strong relationship between these two morbidities. Furthermore there’s a clear association of disease prevalence with poverty: the average poverty rate in the lower left quadrant defined by the median lines is 11.7%, whereas the average rate is 17% in the upper right quadrant.

There are 14 states so far where the political deciders have opted out of expanding Medicaid related to health reform.3 Ten of those 14 clearly have worse population health (they are in the upper right quadrant). For the citizens of those states, it’s not just about being poor and not having access; it’s about being poor and less healthy, and not having access.

What is it here that voids accepted creeds of good works (e.g., the Golden Rule or Matthew 25:35-46)? I contend it stems from the view that the market rules and everything has a price, that competition is the wherewithal, the belief that we’re totally self-reliant and all that’s worthwhile derives from great men so that an unequal society is a good society. If those are a decider’s convictions, especially the great men part, then a preferred health policy would omit the weak: Surely one shouldn’t provide for them; that would just weaken them further as a people. I conjecture these are the notions that support the political decisions which repudiate the common good.

For clarity, I’m adding the following about Medicaid and the expansion.

Medicaid as it currently exists is primarily for children, pregnant women and, long-term care for adults with severe disabilities. Medicaid is managed by the states within federal guidelines; still the variation between states is huge. Childless adults who are not severely disabled do not qualify in most states. In fact, in a majority of states adults with children effectively don’t qualify for Medicaid, just the children. The Medicaid expansion is about changing that for people in need.

To learn more, a primer by the Kaiser Commission on Medicaid is available here, http://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf.

  1. http://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html?hp&pagewanted=print
  2. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8384_es.pdf
  3. Just how many states have opted out is still in flux. I took my best guess based on the information here: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/