Medicaid Expansion triggers can’t fix bad policy
A bill expanding the Medicaid entitlement program in North Carolina was filed this week in the N.C. House. It appears to be on a fast track to pass through that chamber early next week. This vote, likely Tuesday, would call for the single largest expansion of an entitlement program in the state’s history.
However, it comes when layoffs and inflation are creating uncertainty in the economy. Soon there will likely be fewer taxpayers generating revenue for the state and more enrolling in Medicaid. Expansion would fund taxpayer-paid Medicaid benefits to 600,000 mostly able-bodied, childless, working-age adults. The total number would likely be many, many more than that.
In order to get enough votes for the bill, writers built “triggers” into House Bill 76, Access to Healthcare Options, that would end the expansion program if the federal government stops funding 90% of the cost.
End the expansion? How exactly would that work?
Once that is done, the state cannot un-ring the bell or put the toothpaste back in the tube. Use whatever analogy works, but once North Carolina adds what is very likely to end up being 1 million people or more to Medicaid, it will be a herculean lift to kick them off the roles if any of the bill’s triggers come into play.
Today’s lawmakers are agreeing on behalf of N.C. taxpayers to likely take on billions of dollars in additional spending because, with a $31 trillion national debt, it is not realistic that the feds will cover Medicaid expansion indefinitely or in the same form as it is proposed today.
But it’s the moral thing to do because lives will be saved and health care jobs created? Not so fast.
A paper out this winter from the National Bureau of Economic Research, “Revisiting the connection between state Medicaid expansions and adult mortality,” found that the mortality rate in states that have expanded Medicaid remained largely unchanged because of access to care. In other words, that Medicaid card is only worth the paper it’s printed on if you can’t get an appointment.
Researchers reviewed data over a nine-year period from eight states that have expanded Medicaid — Arizona, Illinois, Maine, Michigan, New Mexico, New York, Oregon, and Vermont — and found that Medicaid expansion itself does not necessarily save lives. Unsurprisingly, a truly impactful health care system is far more complicated.
“The main implication of our results, when combined with the prior literature, is that one should not assume that state Medicaid expansions automatically lead to reductions in adult mortality,” the authors concluded. “Instead, the effects of each expansion are likely dependent on a number of factors, such as the availability of services and providers for Medicaid enrollees, the demographic characteristics of the population, and other concurrent changes in the health care system.”
The bill filed this week is what policy analysts call a “clean bill.” It expands Medicaid without the troublesome and needed regulatory reforms that may ruffle lobbyists’ feathers. But expanding the program without expanding access will create more problems than it solves.
It does not open up green space within the industry to grow the Medicaid population and ensure that they can get care, alongside those who have always been on Medicaid and need it the most. People suffering from chronic and debilitating illnesses, for whom Medicaid is literally a lifeline, may suddenly find themselves unable to get the treatments or long-term care because there are so many other people in that waiting room.
Medicaid expansion alone has absolutely no impact on health care supply in North Carolina. It would do nothing to boost the number of available doctors, nurses, medical facilities, or equipment. There is too much bureaucratic red tape in the state’s certificate-of-need laws holding industry growth back.
Reforming CON laws would ease the regulatory burden faced by new medical facilities, and experts argue that such reforms would increase the availability of medical services and lower costs. When combined with the SAVE Act, which would allow nurses to treat patients up to the level of their accreditation without a doctor present, North Carolina would grant full practice authority to a class of providers who could fill some of the gaps in the state’s primary care shortages.
That pool of patients will get deeper once that Medicaid expansion bell is rung, and the state better be ready. For years we have thrown around the 600,000 or 700,000 figure to estimate the number of new enrollees in a Medicaid expansion, but it is likely to be 1 million people or more, with all the costs to go along with it.
In other states that have expanded Medicaid under the Affordable Care Act, experts generally underestimated the size of Medicaid expansion enrollments, underestimated its cost, and overestimated its health benefits
When Colorado expanded Medicaid, they estimated that by 2016 the state’s nondisabled, under-65 Medicaid enrollment would be 710,000. In fact, Medicaid enrollment was over 1.1 million by 2014. Today, Colorado’s Medicaid caseload is about 1.7 million out of a total population of about 6 million. Since the mid-2000s, Medicaid rolls have ballooned from roughly 1 in 12 people to almost 1 in 3 now.
We have the benefit of hindsight and learning from other states. Still, it’s just bad policy.
If this Republican-led N.C. General Assembly is committed to expanding Medicaid, legislators need to be ready, and this bill does not do that. The exponential growth in a federal government-controlled health insurance program will still have enormous costs that fall to N.C. taxpayers, despite a new tax on hospitals that will be inevitably passed to patients.
The massive growth will also squeeze North Carolina’s other priorities like roads and schools. Constituents will not care why there is no money for those other priorities. They will only know that health care lines are longer and taxes are going up under Republican watch.
Putting triggers in the bill may seem reassuring today. But when the budgetary fallout comes, who is going to be the one to end it?