Governors Need to Do the Right Thing for Medicaid, Even If It's for the Wrong Reasons

From time to time the Disease Management Care Blog receives submissions from readers. M'Lynda Owens is a registered nurse with a research interest in population health as well as the provider and payer dimensions of the Medicaid program.

So now several States (Texas, Florida, Mississippi, Louisiana and South Carolina) are exercising their constitutional right, affirmed by U.S. Supreme Court, to opt out of expanding Medicaid to uninsured persons meeting federal poverty guidelines. Their rationale is that they cannot afford the increased costs of an “unfunded mandate” that will accrue once the federal match is reduced to 90%. These five states account for approximately 20% of the population of working poor who would otherwise be eligible for health insurance coverage under the ACA.

Governing.com has posted an interactive state-by-state analysis of the expected impact of ACA. It’s worth taking a look at the map. The number of uninsured in these states ranges from just over 500,000 to 5.8 million, while the percentage of potentially eligible uninsureds ranges from 43% to 63%.

Since many of the states that are opposing an expansion of Medicaid also have the high rates of poverty, obesity, diabetes, and uninsured adults, how could anyone is it believe that this decision is in the public interest? The likely outcome of this venal "opt-out" decision is that all the citizens of these states will have to bear an even greater portion of the burden of the states' responsibility for the working poor, but not in a straightforward fashion. Rather, this burden will take the form of hidden taxes and additional strains on public wellbeing in other sectors such as infrastructure.

The good news is that the uninsured appear to have a strong ally in their states' hospitals. Uncompensated care cost hospitals nationwide a combined $39.1 billion in 2009, according to estimates from the American Hospital Association. According to the website, governing.com, the Texas Hospital Association worries that its members will be forced to pick up the tab for those lacking insurance. One spokesperson stated “Texas hospitals recognize there are concerns with expanding the Medicaid population, but given the state’s high number of uninsured, all options for gaining insurance coverage must be closely considered.” He also said “Without the Medicaid expansion, many will remain uninsured, shifting costs to the insured and increasing uncompensated care to health-care providers.”

These states' governors likely expect that their ongoing attempts to disenfranchise the working poor will be politically popular with voters in the upcoming fall elections. It will be interesting to watch whether the hospitals and their allies, the physicians, will prevail and convince their states' politicians to opt into the Medicaid program and take the money.

If that happens, it'll be because the Governors were persuaded to make the right decision for the wrong reasons.