Editorial: Making the case for Iowa's expansion of Medicaid

The editorial below appeared in the January 22, 2013 edition of the Des Moines Register

Iowa View: Making the case for Iowa's expansion of Medicaid

CHARLES BRUNER is executive director of the Child and Family Policy Center in Des Moines. The organization educates the public and policymakers and advocates on key child policy issues. Contact: cbruner@cfpciowa.orgArnie Bentworth, 46, lives at the local YMCA and has been in and out of hospitals and emergency rooms for bipolar disorder and drug addiction and diabetes. He relies on occasional jobs, local relief programs and some panhandling.He has no health insurance. When he doesn’t have or take his medications, he bottoms out and is a regular at the crisis unit of the public hospital, sometimes logging 10 or more days in the psychiatric ward, as well as emergency room visits and hospitalizations for diabetes.Anne Rasmussen, 38, is a cancer survivor, but continues to struggle with her health. She raised a grown daughter and is now a substitute teacher for the local school, but she does not have the strength to work more than 16 hours per week and doesn’t qualify for health benefits.Her prescriptions cost $800 a month. Her daughter and son-in-law help her out so she can fill them. She often cuts her pills in half, even though her doctor has warned her not to. She has received some county relief to help her pay medical bills, but she has over $10,000 in unpaid hospital bills that have been turned over to a credit agency.These are composite examples of two currently uninsured Iowans who would be eligible for Medicaid if Iowa expands Medicaid under the provisions of the Affordable Care Act. Under the U.S. Supreme Court decision, Iowa lawmakers have the responsibility to decide whether to expand Medicaid coverage to these individuals. If Iowa does so, the federal government will pay over 90 percent of the cost of that coverage.In both instances, what Iowa does will have implications to Iowa taxpayers and Iowans with health insurance, as well as for Arnie and Anne.For Arnie, health insurance under Medicaid will mean he has access to primary care and case management, as well as to emergency room care and hospitalizations. This may enable him to better keep on his medications, manage his diabetes and be less prone to acute episodes resulting in high-cost hospitalizations and emergency room care. In any event, if he is hospitalized or receives emergency room treatment, the hospital will have a billing source, which will reduce the amount of charity care the hospital provides (which is factored into charges to insured patients).For Anne, health coverage will mean that she will have more consistent primary care and have her medications covered. She also will not have the current financial challenges to manage her condition, which ultimately affects her health and ability to work.In both cases, expanding Medicaid will help the individuals served and also promote more cost-effective care, potentially even reducing the use of high-cost medical care.Arnie and Anne and others like them, when they do have medical emergencies, receive care at a cost to hospitals, to county relief and to other Iowans. If Iowa expands Medicaid, the federal government, and not Iowans alone, will cover these costs.Iowans, of course, pay federal taxes — but Iowans will be paying for Medicaid expansion to residents in California and New York, whether or not Iowa expands Medicaid. Even taking into account Iowa taxpayers’ federal contributions to Iowa Medicaid expansion, actuarial studies show Iowans will pay less if lawmakers expand Medicaid than they will for continuing the status quo and picking up those costs through other systems.The Affordable Care Act is a complex piece of legislation. The hospitals serving Arnie will continue to be responsible for providing such care (as charity or bad debt, if not through county relief), but they also will receive less Medicare reimbursements even if state lawmakers reject the option to expand Medicaid coverage.Part of the financing for Medicaid expansion federally comes from reducing the amount hospitals receive under Medicare, in exchange for the increased funding received under Medicaid. While Iowa lawmakers can choose whether or not to expand Medicaid, they cannot choose whether or not these Medicare reductions go into place.Without Medicaid expansion, hospital costs almost certainly will rise for everyone else.In the end, expanding Medicaid is the the most cost-effective way to maintain a health system for all — without incurring major increases in state and local health costs or in increased hospital charges.In addition, it will mean the Arnies and Annes in Iowa will have access to better health care than they have now, which will produce better outcomes for them and for society.