Medicaid Expansion: Cruel, Not Compassionate; Part 1 | Eastern North Carolina Now

Publisher's note: This post, by Brian Balfour, was originally published in the healthcare section of Civitas's online edition.     Coverage Does Not Equal Access to Care

    The Left would lead you to believe that Medicaid expansion would provide low-income North Carolinians with top-notch medical care, create tens of thousands of jobs, and magically be paid for by "someone else."

    The reality is quite the opposite. Medicaid expansion would actually:

• Condemn low-income citizens to an already over-crowded system with little to no access to actual medical care
• Subject those enrolled to poorer health results
• Crowd out Medicaid resources for the most needy in favor of childless, healthy adults
• Cost North Carolina thousands of jobs
• Come with a hefty price tag for North Carolina, and increase the national debt
• Trap more people in poverty
• Make healthcare more expensive for everybody

    What the Left Wants

    One of the long-held goals of the Left in North Carolina has been to expand Medicaid as provided for in Obamacare. Medicaid is a government program jointly funded by federal and state governments that pays for the medical bills of enrollees, which consist primarily of low-income households, pregnant women and people with disabilities.

    Two bills, introduced during the 2017 legislative session, HB 858 and SB 290 - both entitled Medicaid Expansion/Healthcare Jobs Initiative - constituted the latest effort to make this goal law.

    The basic provisions of these bills include expanding the state's Medicaid program to everyone under age 65 not currently eligible for Medicaid earning up to 133 percent of the federal poverty level. The bulk of the expense of expansion would be paid for by the federal government, with most of the state's cost supposedly to be paid for by a hospital tax.

    Fortunately, these bills never so much as saw the light of day in their respective legislative committees. But North Carolinians need to continue to recognize that the Left has not given up on this idea. Expanding Medicaid would have disastrous consequences for those it purports to help, and the state of overall healthcare in North Carolina.

    Coverage Does Not Mean Access to Care

    According to estimates provided in the legislation, Medicaid expansion would add another 630,000 people onto the already over-crowded program by 2019. The goal of expanding Medicaid to hundreds of thousands of North Carolina citizens is sold as a compassionate way to provide access to medical care for low-income families. The reality, however, is that new enrollees would struggle to find access to doctors and the care they need.

    Medicaid rolls in North Carolina have ballooned from about 1 million in 2003 to roughly 2.1 million today. Adding another 630,000 would push the program over 2.7 million enrollees and mark more than 1.7 million new Medicaid patients in just fifteen years.

    All this would take place when the number of physicians accepting Medicaid patients is dwindling. According to state Medicaid Annual reports, from 2003 to 2016, the number of physicians enrolled as Medicaid providers plummeted by more than 10,000, from 36,869 to 26,404, a drop of 28 percent.

    Imagine now adding the equivalent of the entire population of Durham and Cumberland counties combined to a group of people already fighting over a shrinking pool of doctors. That's what Medicaid expansion would do.

    Making matters worse, a 2012 article in Health Affairs found that one-fourth of North Carolina's physicians will not take new Medicaid patients.

    In short, the dwindling supply of doctors is already struggling to meet the demand of the growing ranks of Medicaid enrollees. Expansion would only make things far worse.

    The doctor shortage is especially acute in rural areas, where the concentration of Medicaid enrollees is even heavier, making for even lower doctor to population ratios.

    This is not politics or ideology - this is simple math. Medicaid expansion in North Carolina would not provide access to medical care to the new enrollees, it would simply give them a Medicaid card with little to no hope of actually seeing a doctor when they are sick.

    For example, this 2014 USA Today article looked at the impact in Reno from Nevada's Medicaid expansion. Nevada was one of 26 states to expand Medicaid in 2014, and the article notes that "many new enrollees have been frustrated by the lack of providers willing to see them," and that "(p)hysicians and clinics that treat the poor say they've been overwhelmed by new patients." As Chuck Duarte, the state's former Medicaid chief and director of the region's largest community health center, noted, "We are struggling to keep up with demand for care."

    Research also shows that Medicaid patients - especially children - have far longer wait times to see a doctor or specialist and are more likely to be turned away for treatment by physicians. Trouble finding a regular physician leads Medicaid patients to utilize the highly expensive emergency room for non-emergent care at a higher rate than the uninsured. As one Reno Medicaid enrollee noted in the USA Today article: "I love it on Medicaid because now I can go the emergency room when I need to and don't have to worry about the bill."

    An Asheville Citizen-Times report reviewed the RAND Corporation study showing that emergency room visits are on the rise. The article continued:

• It's often hard for patients on Medicaid-managed care plans to get appointments with primary care providers, with median waits of two weeks, though more than a quarter waited a month or more, leaving them with few options besides the ER, according to the American College of Emergency Physicians. The group also pointed to the nationwide physician shortage.
• "America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately," said its president, Dr. Michael Gerardi. "Just because people have health insurance does not mean they have access to timely medical care." (emphasis added)

    If the radical Left gets its way and as many as 630,000 more people are stuffed onto North Carolina's Medicaid rolls, a big question remains unanswered: Who will these people see to get care? Medicaid enrollees already struggle to access care in a timely manner. Imagine how much worse the problem will be when 630,000 more people are added to the program.

    The bottom line is this: those advocating for Medicaid expansion want to condemn low-income people into an already overcrowded system that is simply incapable of providing adequate medical care. That's not compassionate - that's cruel.

    Medicaid Provides Poor Health Results

    Due in no small part to the extremely poor access to care, health outcomes for Medicaid enrollees are subpar.

    As Steve Anderson, the Kansas budget director from 2010 to 2013 and former board member in the hospital industry pointed out in this article, "Any discussion of Medicaid should begin with its track record on patient health. On that score, Medicaid is an abject failure."

• Medicaid recipients consistently fare poorly on medical access and outcomes. Their access to doctors and specialists is significantly lower than those with private insurance. Their death rate in hospitals following surgery is twice as high. And children on Medicaid have much longer waits to see doctors, along with a higher chance of being turned away by health care providers.

    Moreover, a 2011 groundbreaking study in Oregon showed Medicaid enrollees don't experience any better health outcomes than the uninsured, and often times experience even worse outcomes.

    The study examined Medicaid expansion in Oregon, comparing outcomes for people who received coverage versus a control group that did not have health insurance. It found some limited benefits of Medicaid enrollment, like reduced rates of depression. But in terms of overall health outcomes, there was no difference between the Medicaid group and the control group in terms of blood pressure, cholesterol, diabetes, or obesity - all indicators that should have improved over the span of the study.

    If the goal of Medicaid is providing better health care to the poor, the evidence suggests it is failing miserably, and the failure comes with a huge price tag.

    Expansion Would Crowd Out Care for the Most Vulnerable

    A 2012 study by the Urban Institute examined the demographic makeup of the uninsured that would be newly eligible for Medicaid under Obamacare's expansion. Nationally, about 4 of every 5 newly eligible for Medicaid would be a working age adult with no dependent children. In North Carolina, that figure is more than 3 of every 4 newly eligible adult.

    Furthermore, according to the Obama administration's own Department of Justice, nearly 1 in 3 of those who become newly eligible for Obamacare's Medicaid expansion would have had previous time served in prison or jail.

    In other words, the majority of people who would be covered under Medicaid expansion in North Carolina would be healthy, childless adults of working age or ex-cons.

    This new group is who would be competing for care - from an exceedingly short supply of doctors - with the traditional Medicaid population of poor children, pregnant women and the disabled.

    And because the federal government would pay for a higher percentage of the cost of the newly eligible under expansion compared to the traditional Medicaid population, states would favor directing resources to the newly eligible population over the most vulnerable populations.

    Part 2 of this article will examine the rest of the negative consequences of Medicaid expansion.

    [i] Figure taken from Medicaid Annual Reports for FY 2003 and FY 2016. Available online at: https://files.nc.gov/ncdma/documents/Reports/Annual-Reports/Medicaid-Annual-Report-SFY-2003.pdf

    https://files.nc.gov/ncdma/documents/files/Medicaid-Annual-Report-State-Fiscal-Year-2016.pdf