America in 2016?

Today's map pictures the United States in 2016.  Half the states and DC have implemented the Medicaid expansion provision of the Affordable Care Act ("Obamacare").  Massachusetts has had basically the same system ("Romneycare") since 2006.  If the other 24 states and DC follow a similar path as Massachusetts, what could the US look like health-wise in 2016?  Imagine an America where half the country had Medicare, Medicaid, and Social Security...and the other half didn't.  What would the health and economic results look like?

If the percentage of uninsured people drop to match Massachusetts' 2010 rate of 5%, then in these 25 states and DC around 1 in 20 people will still be uninsured.  That is quite a bit lower than in many of the other 25 states where 1 in 4 people may be uninsured.

Based on Massachusetts' experience, here are some likely outcomes for the states implementing Medicaid expansion.  With all these newly insured Americans seeking healthcare, demand for medical appointments will be high.  ER visits should also go up.  Wait times for appointments will be longer.  Massachusetts has the highest doctor-to-patient ratio in the US, so this crunch may be even more challenging in other states.

Healthcare delivery also may change with a greater reliance on nurse practitioners, physician assistants, and other means to provide care to more people.  With preventative health screenings now free, the percentage of women 50 and older who have had a recommended mammogram jumps to over 80%.  Hospitals in these states who previously had to provide free care to the uninsured rushing to ERs will now be compensated for the medical care they provide.  With the Federal government picking up the tab for the Medicaid expansion 100% until 2017 and then reducing its coverage percentage to 90% by 2022, states expanding Medicaid will be receiving a massive influx of Federal tax dollars translating probably into more healthcare jobs, a boost in students seeking medical careers, construction jobs as clinics and hospitals expand, and other economic benefits from this huge infusion.

Map courtesy of Kaiser Family Foundation

For the other 25 states, things may potentially be quite different.  The first map showing the US in 2016 likely exaggerates the percentage of uninsured.  The darker brown colors show the actual 2010 percentage of uninsured in each of the 25 states not expanding Medicaid.  Even in these states the Affordable Care Act still mandates all but a handful of groups must be enrolled in some type of health insurance.  Low income Americans are eligible for subsidies to buy private health insurance, but a sizeable chunk of the working poor are being covered in other states by the Medicaid expansion.  As originally planned, these individuals earning between 101-135% of the Federal poverty limit were to be covered by the Medicaid expansion and are not currently eligible for the subsidies.  The decision by some states to not expand Medicaid leaves these low income Americans in the so-called "Medicaid doughnut hole" -and thus are likely to remain uninsured.  This doughnut hole will keep 5 million Americans from getting health insurance in the 25 Medicaid doughnut hole states.  Many of these states already suffer some of the worst health outcomes for their people in the country.  If half the country is getting to see a healthcare provider and getting regular preventative care and a big chunk of Americans in other states are not, we may start seeing a widening health gap between the healthy states and the sick states -especially between the sick South and the healthier rest of the country.

Residents in states that have chosen not to expand Medicaid often face other roadblocks to getting health insurance.  A recent study finds that states which set up their own health exchanges are doing a much better job at enrolling their uninsured citizens than those relying on the Federal healthcare.gov exchange.  Florida's governor even went so far as to ban health department workers from assisting citizens in signing up for health insurance through the Affordable Care Act.  Several FL counties are getting around the ban to help their citizens.

On the economic front, these No-to-Medicaid-Expansion states face the economic short end of the stick.  Hospitals serving the uninsured still must by law provide care to those with life-endangering conditions.  In effect most hospitals almost never turn anyone away.  The Federal government for years has provided a fund to help compensate these hospitals who treat large numbers of the uninsured.  With the ACA planned to cover most all citizens, this fund is cut in half by 2016.  Now with 25 states opting out of expansion, these hospitals will have less Federal dollars to offset their costs.  One of their few options is to raise premiums on their insured customers.  So, expect insurance costs to rise more in the non-expanding states and the possibility of cash-strapped rural and inner city hospitals to close in bankruptcy.  The tax dollars of these mostly Republican Red State voters will be going to help support the Affordable Care Act.  While a chunk of these dollars are flooding into other, mostly Democratic Blue States' Medicaid programs, hospitals, and healthcare providers, they will be draining out of these Red states.    This scenario is pushing hospital associations in a number of states to ask their governors and legislatures to expand Medicaid.  Indiana and Pennsylvania are already working on this.  Republican governors in Arizona, New Mexico, Michigan, etc. already came come on board by expanding Medicaid in their states.  So by 2016 we likely will see several other states expand Medicaid as economic and health realities trump politics.  

Many things may change by 2016, but there is a real possibility of a growing economic and health divide to emerge between the states insuring millions of their uninsured and those that do not.

The ACA: Health Rankings and Health Exchanges

Most of the least healthiest states' governors opted to not pursue a state-level health exchange.

Of the 12 unhealthiest states in 2012, only one -Kentucky- opted to set up its own state health exchange under the Affordable Care Act.  Arkansas and West Virginia chose to set up joint Federal-state exchanges. All three states had Democratic governors in 2012.  

One other state in the bottom quarter of health rankings also had Democratic governor in 2012.  Missouri voters in 2012, however, passed a law blocking their governor from setting up a state health exchange. 

The other 8 unhealthiest states currently have Republican governors.

These maps underscore the political element involved in decisions to expand health insurance to the states with the most serious health challenges.

Ranking America's Health

The Southern states rank as America's least healthy.

As a Southerner, I'm somewhat used to rankings that often find the Southern states where I live, work, and visit family as among the worst on a host of social indicators:  poverty, low education, and disease.  The University of Wisconsin recently received funding from the Robert Wood Johnson Foundation (RWJ) to synthesize a large number of health indicators and rank the states and counties for health.  America's Health Rankings (for states) and its sister site, County Health Rankings, generated considerable news coverage and controversy as you would expect anytime you rank places.  Below is a map of the health rankings for the year the ACA was enacted by Congress:  

As you can see, the least healthy states tend to be in the southern tier of the country.  Of the former Confederate states, only Virginia ranks among the healthiest half of states.

The ACA: Medicaid Expansion

Medicaid expansion leaves out the majority of America's uninsured.

Via: The Advisory Board Company

One of the primary mechanisms to insure low income Americans under the ACA is the expansion of Medicaid.  Currently households earning up to 100% of the Federal poverty limit can enroll in Medicaid, the public health insurance program jointly administered by the individual states and the Federal government.  The ACA seeks to expand Medicaid to cover households earning up to 134% of the Federal poverty limit (FPL).

When the US Supreme Court upheld the constitutionality of the ACA as a tax, the Court's decision ruled that expanding Medicaid was optional for the states.  As a result, most of the states with Republican governors have chosen to not expand Medicaid -citing fears of the program busting state budgets.  The Federal government pays 100% of the costs of expansion for the first several years and then pays 90% of the costs after the first several years.

The results create a number of consequences.  More than half of America's uninsured live in the red states opting not to expand Medicaid.  Texas and Florida especially contain large numbers of uninsured Americans. Consequences:

a. Many or even most of the uninsured poor will not be covered by Medicaid as planned.

b. In 2014 all Americans -with a handful of exceptions- must show they have health insurance coverage.  For households earning 101-134% or so of the Federal poverty limit and who live in one of these non-expansion states, they currently will not get Medicaid or the subsidies designed for households earning 135% or higher of the FPL.  So unless this "insurance donut" is fixed, these working poor will have the additional burden of non-subsidized health premiums or a fine for not having health insurance.  Or they will have to move to a state that has expanded Medicaid.

c. Hospitals -especially those rural and inner city ones treating large numbers of uninsured- currently can dip into a Federal fund to offset the costs of treating uninsured patients.  The ACA expected the vast majority of these uninsured patients to be covered by Medicaid or another type of private insurance by 2014 and moved half of this fund to paying for the ACA.  Now the Federal government is delaying the reductions in this hospital pool.  Starting in 2016, however, the pool for offsetting the costs of treating the uninsured will be halved.  For those hospitals in non-expansion states, they must still treat or stabilize any patient entering their doors -at least if the hospital receives any government funding such as Medicare or Medicaid patients.  Without the expansion they have only one way to offset their costs:  raising premiums on insured patients.  Thus, the choice to not expand Medicaid may lead to higher premiums for the insured in these states or the closure/bankruptcy of hospitals.

The ACA: Health Exchanges

Whether your state has its own health exchange or relies on the troubled Federal exchange, healthcare.gov, depends largely on whether you have a Democrat or Republican as governor.

History is full of ironies.  

Most Americans get their medical insurance from their employers.  This system is largely a fluke of history.  1930s Depression Era laws limited the ability of American employers to give raises.  So when the economy began to boom during and after World War II, employers turned to offering benefits as a way to recruit and retain workers.  In other countries, health insurance coverage usually evolved in the post-war, mid-20th century as a government service like the military, police, schools, and fire departments.  

For the US, 1965 was a crucial year.  It was in this year that Medicaid and Medicare started as programs to help certain groups of uninsured Americans.  By 2010 the public health insurance landscape in the US had become a patchwork of programs:

• Medicare for seniors
• Medicaid for low income Americans -mostly seniors and children
• VA (Veterans Administration) for military veterans
• TRICARE for active duty military and their families
• CHIP (Child Health Insurance Program) for low income children
• IHS (Indian Health Service) for Native Americans living on reservations

Ideas for how to cover the big group -the working poor- left out by these programs goes all the way back to the Nixon administration.  Ironically, largely Republican think tanks and policy experts created a system of funneling the uninsured into private health insurance programs using subsidies for the poor and individual mandates to require younger, healthier, uninsured people to buy private health insurance.  It was this basic program which Republican Governor Mitt Romney installed in Massachusetts.  And it is this system of using private health insurers and government subsidies which is the same model making up Obamacare.

Even more irony:  More liberal Democrats wanted to simply expand Medicaid to cover the uninsured and have a tax withdrawn from people's checks in the way we pay for Medicare.  Some political commentators argue the use of the Romneycare model -plus the adoption of more than a 100 Republican amendments to the ACA- largely was a failed carrot to entice Republican legislators to vote for the ACA.  So, while the ACA is largely a Republican idea filled with Republican amendments, the ACA passed with zero Republican votes in 2010.  

Thus, it comes as no surprise that most Republican governors have opted to not set up a health exchange for their state and instead let the Federal exchange fill the void.

The Affordable Care Act (ACA): Obamacare Comes to America

Congress enacted the Affordable Care Act -AKA Obamacare- in 2010.  Various elements of the new healthcare law have been rolling out in the past several years, but the key health exchanges opened this month.  My next series of maps and data will focus on the ACA.

If you are interested in my own personal odyssey enrolling for coverage, check out one of my other blogs, My ACA Experience.