It is common for people to assume that President Obama's Affordable Care Act will lead to universal coverage, after all that was its stated aim.
Coverage under the plan, which will not be fully implemented for seven more years, would be driven by a law making private health insurance compulsory, with an individual mandate to purchase health insurance or else pay a fine, for all but the poor, much like the reform led by Governor Romney in Massachusetts. For the poor, the goal was to expanding Medicaid eligibility to everyone with an income below 138 percent of the federal poverty level.
But the Supreme Court, when it upheld the law as constitutional overall, also ruled that states could opt out of the Medicaid expansion.
We now know that a significant number state governments will opt out, in the end perhaps more than twenty in all. Texas, Florida, Kansas, Alabama, Louisiana, Mississippi, Georgia, Wisconsin are among the states that have decided not to expand Medicaid to all of the poor.
Some commentators and journalists have laid the blame at the feet the Supreme Court for the fact that the President's "healthcare overhaul" will fall far short of universal health coverage for our nation. They cite projections that the reform was designed to enroll 16 million of today's 50 million uninsured people in Medicaid programs. The point is that that many millions will not become eligible as long as their state governments opt out of expanding Medicaid.
But being eligible for Medicaid is different from enrolling.
In a study published this month on the Health Affairs blog researchers Rachel Nardin, Leah Zallman and others estimated the impact of Medicaid expansion on the uninsured. They took into account the fact that people have to enroll in Medicaid by basing their estimates upon published take-up rates for public programs, prior publications, and Congressional Budget Office estimates regarding implementation of the President's healthcare plan. They found that the President's plan, overall,
> ... will minimally alter the demographic composition of the uninsured, regardless of whether undecided states opt-in or out.
> While Blacks and Hispanics will continue to be overrepresented among the uninsured, the majority will be non-Hispanic, white, low-income,
> working-age adults, many of them employed. The majority (around 80 percent) of the uninsured will be US citizens, irrespective of states’ acceptance of Medicaid expansion. More than 4.3 million children and nearly 1.0 million veterans will remain uninsured under either scenario.
The study also looked at the state governments presently undecided about whether to opt in or out of Medicaid expansion. The researchers found:
> if all currently undecided states opt-in, 29.8 million people will
> remain uninsured, whereas if all opt-out, the number of uninsured will
> total 31.0 million, 1.2 million above the opt-in scenario.
Recently in the hospital I met a patient, a woman with limited intellectual ability and serious chronic health issues who had moved from another state so that her sister could help her each day.
Applying for Medicaid seemed beyond the abilities of our patient, even with her sister's help. Yet by enrolling in Medicaid our patient could gain access to medications that would help keep her out of the hospital.
Medicaid expansion will help our nation's poor and blocking it seems an unnecessary cruelty on the part of state governments. Because the President's reform also will reduce funding to safety-net hospitals, financial devastation will continue to plague poor Americans who become seriously ill, more so in those states that opt out.
On the other hand Medicaid remains a poor program for poor people, with poor reimbursement for specialty care and hospital care. State-by- state privatization schemes and funding cutbacks continue undermine access to care for those who have Medicaid. Even if all of the poor were automatically enrolled in Medicaid our health system would still remain indefensible, for it would codify an unjust two-tier system, burdened with deep racial disparities.
The Affordable Care Act will fall well short of providing affordable health coverage to all Americans. Tens of millions of people will remain uninsured. We still need a program that will make sure that everyone receives care, not coverage.
If access to comprehensive care is the goal, as it should be in a great modern democracy, then nothing short of a system of national health insurance, everyone in, nobody out, will work.
Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.
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