North Carolina would face a substantial fiscal impact if the legislature agreed to opt for Obamacare’s Medicaid expansion. But expansion also would lead to human costs. I’ll touch on three:
1. Private coverage crowd-out
If North Carolina were to expand Medicaid, approximately 180,000 North Carolinians who currently benefit from a heavily subsidized private coverage plan with incomes between 100 percent and 138 percent of the federal poverty level would be thrown into Medicaid — with its track record inferior to private health insurance. As a result, expansion of eligibility levels for government health insurance programs would crowd out access to private coverage.
Studies indicate that the crowd-out effect contributes to the fact that six out of 10 people on Medicaid once had private coverage. Expanding Medicaid would add an additional 500,000 enrollees to our state’s Medicaid program.
The heavier the Medicaid caseload, the more providers will have to make up for being paid below market levels by negotiating higher payment through private carriers — ultimately passing on these costs to consumers in the form of higher premiums. The Galen Institute explains:
In 2008, Milliman, the leading health insurance consulting firm, estimated that the average American family with private health insurance paid $1,800 more in premiums because of this cost-shifting phenomenon. By dramatically expanding Medicaid, states will impose a hidden tax on tens of millions of people with private insurance.
2. Deteriorating Access To Care
People often interchange the terms “health coverage” and “health care,” but they are two very different concepts. At present, one in four physicians in North Carolina does not accept new Medicaid patients. Granted, Medicaid acceptance rates rank above average in this state compared to other states, yet access to care can deteriorate with more patients on the program.
Medicaid was originally designed for low-income mothers, children, pregnant women, plus the elderly, blind, and disabled — our nation’s most vulnerable citizens. Qualifying for Medicaid was originally based on the condition of either having a severe disability or dependents.
Expanding eligibility for Medicaid puts traditional program enrollees at greater risk. They will have to compete with a half-million more people for adequate access to health care — 82 percent of whom are able-bodied childless adults. The Foundation for Government Accountability cites this statistic from the Urban Institute in the chart below:
3. Health Outcomes
Medicaid fails the poor. Avik Roy, senior fellow at the Manhattan Institute and Forbes opinion editor, even wrote a book about it. It is called How Medicaid Fails The Poor. Roy extrapolates on this by referencing the 2008 Oregon Health Insurance Experiment, the gold standard of studies in which a randomized control trial tested whether Medicaid is significantly effective when measuring blood pressure, high cholesterol, hemoglobin levels, and long-term cardiovascular risk between a cohort of patients on the program compared to a similar number of patients who remained uninsured.
Two years later, the authors detected that, overall, Medicaid had no significant effect on measured health outcomes between the patients randomly assigned to Medicaid compared to those not having insurance.
Just looking at the background story of how the OHIE came about points out Medicaid’s recurring health care cost and access problems. In 1993, Oregon expanded its Medicaid program to the working poor. It wasn’t too long until actual enrollment exceeded projected enrollment, causing a state budgetary crisis.
Oregon therefore froze its Medicaid enrollment and eventually reopened it to allow for an additional 30,000 newly eligible enrollees to apply for a Medicaid lottery out of a waiting list of 90,000 people.
Katherine Restrepo is Health and Human Services Policy Analyst for the John Locke Foundation.