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.