Hopping Over The Affordable Care Act
While I appreciated reading a column this week by Hoppy Kercheval about the ACA, I was disappointed to see him recycle the same arguments that have been disproved for months now.
Hoppy's biggest concern is how we're going to pay for Medicaid expansion in the future. He points out that the actuarial estimates showed that over 10 years West Virginia will take in $5.2 billion in federal funds while having to spend an additional $375 million in state dollars. What he doesn't consider is the impact of all that additional money on the state's overall economy. Many states that debated Medicaid expansion did a study on the economic impact of expansion (unfortunately, Governor Tomblin never requested one) and in most states that did them, it was determined that there would be a net economic gain. Next-door neighbor Kentucky, for example, found that expanding Medicaid would save the state $800 million over the next eight years. This is because the increased federal and state dollars will create permanent jobs, an estimated 16,700 of them in Kentucky alone, which generates significant economic activity and tax revenue that otherwise would not exist. Using Kentucky as a guide for a little napkin math, I previously estimated that West Virginia could see the creation of over 6,500 jobs and a net positive economic impact of over $40 million per year. Put another way, it would cost West Virginia more money not to expand.
Another concern of Hoppy's is that the federal government will renege on its promise to fund 90 percent of the Medicaid expansion in the years ahead. However, there is no historical precedent in which the federal government has backed out on a legal promise to states to fund programs. Had something like that ever happened, especially at this scale, it may be a reasonable argument, but otherwise it sounds little different than "I don't want to take this new, better job because I may get laid off one day."
Hoppy's next concern is that "there is no guarantee that providing people with free health insurance…will encourage people to make price-conscious decisions about their care." This ignores the fact that uninsured people who get sick or injured are forced, by default, to make the least price-conscious decisions possible. If you are uninsured, you will be unlikely to afford preventive care but that doesn't mean you won't seek care when your condition gets so bad you really need it. Many of these folks enrolling in Medicaid today have conditions like diabetes which can be effectively controlled at a much lower cost with regular care than being forced to wait until they go into diabetic shock and show up in an ER via ambulance.
There's a related point to be made here that lack of price transparency, arguably one of the biggest problems in American health care, makes it difficult for anyone to make price-conscious decisions. Very rarely will anyone, whether that's your doctor or your insurer, be able to tell you in advance how much a particular visit or procedure will cost. Imagine going to a restaurant with no prices on the menu and neither the waiter nor the chef are willing or able tell you how much your dinner will cost until they send you a bill in the mail weeks later. You'd have quite a hard time making price-conscious decisions without that information, but that is the very frustrating reality in which we currently live.
Hoppy's next concern exemplifies the disingenuous tactic that opponents of the ACA often use which is to point out historical problems with our health care system and suggest they are somehow related to the ACA. He states that West Virginia has a provider issue. While this is both true and false, most importantly it is nothing new. First off, when you look at the state as a whole, we actually have a higher rate of primary care physicians than most states while we also have the highest proportion of Federally Qualified Health Centers in the U.S. (Hoppy acknowledges both of these, which contradicts his opening statement). The bigger point though is that provider access issues are highly localized. This is just as true across the country as it is in West Virginia. For example, Ohio County has a ratio of one primary care doctor per 632 residents, ranking it one of the highest in the entire U.S., while Clay County, with only one primary care physician per 4,679 people, is much lower than the national average. But this issue of provider shortages in rural or underserved areas has been acknowledged for decades. It could be argued that these issues may be exacerbated as more people gain health insurance but it could also increase the number of providers willing to practice in underserved areas as more people in the community can pay for care. And even if it were true that we don't have enough providers, is the acceptable course of action limiting the number of people who can afford to access those providers?
None of Hoppy's concerns that he expresses here are anything new, they are all issues that have been addressed and disproven across the country. Are there consequences to expanding Medicaid? Certainly there are some, but the evidence has shown that they are greatly outweighed by the benefits, both for the economic health of our state and the physical (and financial) health of its residents.