By Grace-Marie Turner and Avik S. Roy
1. Virginia’s Medicaid spending will explode
According to a forthcoming publication from The Heritage Foundation, Medicaid spending will increase dramatically as the federal match rate for the expansion population begins to drop and as more and more Virginians are enrolled in the program.
2. Medicaid harms the poor.
The Medicaid program is so badly broken that it actually harms the people it is intended to serve. Mountains of clinical literature show that many patients on Medicaid have poorer health outcomes than those with no insurance at all. The largest such study by far, conducted by surgeons at the University of Virginia, examined outcomes for 893,658 individuals undergoing major surgical operations from 2003 to 2007. It found that patients on Medicaid were 97 percent more likely to die in the hospital, after surgery, than those with private insurance, even when adjusting for age, gender, income, region, and health status. Medicaid patients were 13 percent more likely to die than those who were uninsured.
This is because the Medicaid program pays doctors and hospitals far less than private insurers do, leading many doctors to drop out of the program entirely. In 2008, the Virginia Medicaid program paid doctors 29 percent less than private insurers did. In states with expansive Medicaid programs, like California and New York, Medicaid pays doctors 62 and 71 percent less, respectively. When Medicaid patients can’t get predictable access to care from physicians, their cancers go undiagnosed and their heart conditions go unmanaged. Virginia should instead insist that Washington provide more flexibility with Medicaid spending so the Commonwealth can provide them the dignity of private insurance.
3. Medicaid’s access problems will get worse, as more doctors drop out.
According to the Urban Institute, there is considerable concern about whether there will be enough doctors to see the influx of new Medicaid patients. It seems unlikely there will be increases in permanent participation among privately practicing physicians with the temporary increase in federal payments for primary care physicians for two years. The biggest problem in Virginia will be in developing sufficient capacity in the southern and southwestern parts of the state. In these areas, enrollment increases will be the largest and provider shortages the greatest.
4. Will the Medicaid expansion create 30,000 jobs in Virginia?
The claim that Medicaid will “create jobs” uses out-of-date Keynesian models that have been eminently disproven over the last six years. These same forecasts were used to predict that the American Recovery and Reinvestment Act of 2009 (ARRA)—commonly known as the “stimulus”—would bring the national unemployment rate below 6 percent by 2012. Instead, the unemployment rate has remained in the high 7% to low 8% range.
Those who claim that the Medicaid expansion will create jobs should be required to explain, specifically, how their forecasting models differ from those used to project unemployment rates under the ARRA.
5. Will 400,000 people be denied coverage if Virginia turns down the Medicaid expansion?
Studies that claim several hundred thousand Virginians will be denied coverage if the Commonwealth doesn’t expand Medicaid do not account for crowding out of private insurance. But Medicaid will end up replacing higher-quality, employer-sponsored health coverage for tens of thousands, if not hundreds of thousands, of Virginians. While these individuals will still have “coverage,” and therefore will not increase the ranks of the uninsured, the quality of their coverage will meaningfully decrease.
Coverage is not the same thing as care. Medicaid has the worst health outcomes of any insurance program in the developed world. While Medicaid recipients have a card saying that they have health insurance, they have very poor access to physicians, making it hard for them to get care when they need it, as proven by the University of Virginia study cited above. Expanding Medicaid will create a cascade of unintended consequences for Virginia taxpayers and citizens.
6. Medicaid raises premiums on those with private insurance.
One of the hidden costs of expanding Medicaid is its impact on people with private insurance. Because both Medicaid and Medicare underpay doctors and hospitals for their costs of care, these providers make up the difference by charging higher rates to private insurers. In 2008, Milliman, the leading insurance consulting firm, estimated that the average American family with private health insurance paid $1,800 more in premiums because of this cost-shifting phenomenon. By dramatically expanding Virginia’s Medicaid program, the Commonwealth will impose a hidden tax on the millions of Virginians with private insurance.
Because expanding Medicaid leads hospitals and doctors to shift costs onto patients with private insurance, this makes private insurance less affordable and increases the number of people without insurance.
Therefore, expanding Medicaid will lead to more people losing private health insurance – a fact that is not included in the Urban Institute or Kaiser estimates.
7. Medicaid’s undercompensated care is a bigger problem than uncompensated care for the uninsured.
In policy circles, there is much discussion of the “uncompensated care” problem, whereby the uninsured use emergency rooms to get routine care. But the problem of undercompensated care—that Medicaid and Medicare do not pay hospitals enough to cover their beneficiaries’ costs—is a larger one, and contributes to an equally large amount of inappropriate emergency room use. In Ohio in 2010, for example, hospitals spent $1.1 billion on charity care, but lost $1.3 billion on Medicaid patients.
8. Expanding Medicaid will expose Virginia to immense amounts of fraud and waste.
Official federal estimates show that at least 10 percent of Medicaid payments are fraudulent. Many prosecutors believe that the figure is closer to 30 percent. Unfortunately, health-care providers often aggressively resist efforts to police fraud and waste because excess Medicaid spending often accrues to their benefit.
In neighboring North Carolina, State Auditor Beth Wood, a Democrat, recently completed an audit that found that the state’s Medicaid program endured $1.4 billion in cost overruns each year, including $375 million in state dollars. As a result, North Carolina has decided not to expand its Medicaid program. Before considering a Medicaid expansion, Virginia should conduct a similar audit of the program and demand flexibility for reform.
9. Virginia will be exposed to higher Medicaid costs when Washington recalculates its matching payments.
While the Affordable Care Act covers most of the cost of the Medicaid expansion in the near-term, it is almost certain that, in outlying years, the federal government will attempt to reduce entitlement spending by reducing its matching payment for the expansion. Indeed, President Obama proposed doing just that in his fiscal year 2012 budget, which would have reduced Medicaid spending by $100 billion over ten years.
In addition, many states have made extra money from their Medicaid programs by taxing providers and insurers for participating in the program. These accounting gimmicks will almost assuredly be prohibited in future federal budget negotiations, leaving states on the hook for more Medicaid spending.
10. By rejecting the Medicaid expansion, Virginia encourages other states to do the same, reducing waste of taxpayer dollars.
Many states still are deciding whether or not to expand their Medicaid programs under the ACA. A principal justification that Medicaid advocates use is that declining to expand Medicaid means that state taxpayer dollars go to fund Medicaid in other states.
But the large “blue states” that have gone along with the Medicaid expansion will see relatively little in increased federal spending because they had already expanded their programs beyond the ACA mandate. Indeed, only half of the funds dedicated to the Medicaid expansion are being spent outside the South. Large “red states,” on the other hand, where the ACA’s Medicaid dollars are directed, have mostly rejected the expansion.
Virginia, as a large swing state, will set an example to other states that are deciding what to do about the Medicaid expansion. Ten states have already rejected the expansion, with 20 others undecided. If Virginia joins these ten, it will do much to limit spending of Virginia taxpayer dollars by other states.
11. Medicaid will worsen the cycle of dependence and harm the economy.
As noted above, a significant amount of Medicaid spending goes to fraudsters. All Medicaid spending takes money out of productive sectors of the economy and re-routes it into existing health care providers. Most importantly, Medicaid imposes a huge disincentive on the poor to find work.
If Virginia chooses not to expand its Medicaid program, able-bodied adults who seek work and who successfully cross the poverty line should have the option of private insurance. This should be the focus of the Commonwealth’s negotiations with Washington – seeking a united front with other states. This is a morally superior approach, one that will increase the incentives for employment and stimulate the economy through privately-generated income.
12. Exchanges will provide better health outcomes, far less fraud, and fiscal certainty.
If Virginia expands its Medicaid program, as many as 250,000 Virginians between 100% and 138% of the federal poverty will be added to the Medicaid program. The Commonwealth should demand more control over how subsidy money is distributed to Virginians so they can seek higher-quality private insurance. Subsidized private insurance would pay doctors and hospitals more than Medicaid will, affording Virginians access to a broader network of health services, and in turn will produce better health outcomes.
Private insurers are much better at rooting out waste and fraud compared to public insurers, reducing the incentive for Medicaid fraudsters to come to Virginia. A carefully-negotiated compromise will mean the Commonwealth is protected when Washington attempts to increase Medicaid costs to Virginia later on. And, most importantly, it will allow Virginia residents the opportunity to get better quality of care and coverage through private insurance.
Grace-Marie Turner is president of the Galen Institute (firstname.lastname@example.org), and Avik S. Roy a senior fellow at the Manhattan Institute (email@example.com).