Expansion would provide free
insurance to those making 25-100 percent of the federal poverty income limit;
currently, these people obtain medical care by appearing at a health care
facility where they must be treated or referred at no cost to put them out of
medical danger. The state estimates that through 2023 expansion
would have cost the state at least hundreds of millions of dollars. In the
most likely scenario, by 2030 the cost to taxpayers would end up about $1
billion extra under expansion than under the current regime. Under the least optimistic
scenario, costs would have been over $2
billion extra through 2023.
Jindal has pointed to the Medicaid program’s
structure as a major reason for the considerable costs, and proposed his own
federal overhaul to make it more efficient. Those ideas translated
to the state level were passed into law this year, but would need those
federal changes to implement. With that unlikely to happen until election of a
reform-minded president in 2016, some supporters have tried to grasp onto other
states’ efforts that don’t ask for major federal reform but with tweaks.
When in 2013 the Legislature
debated the issue, proponents introduced a bill emulating the approach by
Arkansas, which took federal dollars to give to individuals enough money to buy
private policies. But this provided no real solution because it maintained inflexible
federal standards in areas such as payment amount, benefits composition,
co-payment policies, and other issues, and wisely was rejected.
Earlier this year supporters began
beating the drums again for Louisiana to act similarly when an even broader
waiver was sought by Indiana to do the same thing, but with fewer restrictions.
Even as this appeared
better as it could wring more inefficiency out of the system, it has gone
nowhere because the federal
government continues to refuse to grant a waiver that contains the very
provisions that makes it a less wasteful, less objectionable plan.
And now the Arkansas experiment is
unwinding to the extent that its legislature
looks likely to defund the entire thing. The problem, predictably, has been
the relative
inflexibility of the program has pushed costs higher than anticipated onto
the state – and this before the state must begin picking up costs in 2017 than
will rise by 2020 to 10 percent of the total spending that does not include
that extra already being paid above the waiver-mandated reimbursement cap that
was unanticipated. Worse, there’s no guarantee that that 10 percent figure that
applies to all states in 2020 and after won’t be increased by federal statute
in the future.
The Indiana experience shows the
unwillingness of the federal government to make even some of the changes Jindal
had suggested as part of his reforms. The Arkansas experience shows the
costliness to taxpayers in not incorporating those reforms. Another state
reform in Oregon, which actually predated expansion under the Patient
Protection and Affordable Care Act, showed no
statistically improvement in objective health outcomes by those new
Medicaid enrollees compared to the uninsured population. This experience demonstrates
no benefit to expansion.
And the national experience of
other states that expanded Medicaid, for the next two years still paid fully by
the federal government, is that it will cost more than expected because emergency
room utilization has a whole has gone up as a result of expansion. This is
a result both of habits of the new enrollees and because fewer doctors are wanting
to participate in traditional Medicaid because of reimbursement and regulatory
issues.
All of this experiential data reconfirms
the wisdom of Jindal and the Legislature not to pursue Medicaid expansion. It
remains a bad deal for both taxpayers and the indigent, and the only question surrounding
any of this is why, in the face of such evidence, there are those who continue
to want to see it come into fruition.
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