Posted on | March 27, 2017 | No Comments
In a recent analysis of the U.S. and Canadian health care systems, two things were clear. First, Canada Health Care was planned, and our’s just happened. And second, both nations favored regional over federal delivery systems. In the U.S., that meant a strong bias toward state management, while in Canada the provinces and territories individually control the majority of funding, coverage, and execution. For Canada this has meant tolerance for variability, which has been counter balanced by a high degree of transparency.
In the U.S., we have preferred more opacity and fudging. Every time we’ve sided with total voluntary participation, we’ve landed with egg on our face. But that has begun to change as last week’s vote on Trumpcare revealed. And Medicaid is where we now see serious cracks in conservative armour.
To review, the ACA when passed in 2010 required that states offer Medicaid to all citizens of the state who fell below 138% of the poverty level ($32,913 for a family of four.) The federal government at first agreed to cover 90% of the expenses for new enrollees and then up’d it to 100%. As we all know, the Republican Congress then loudly announced a call to arms to kill the President’s signature legislation, driving loyal Republicans in state houses everywhere underground. All manners of deception and subterfuge were legitimized for the next 7 years.
Still, in 31 states and in DC, Medicaid expansion or a federally approved alternative has occurred, including 10 with Republican governors. More importantly, even in the short term (especially with the opioid epidemic surging) the positive health outcomes associated with Medicaid expansion have been dramatic. On multiple measures, the populations covered are healthier, have greater access to care, delay less in getting needed care, visit emergency departments less and are less financially strained. The states budgets have improved as well.
Pragmatic Republican governors like John Kasich delivered direct messages during the Presidential campaign, which might be roughly translated, “Don’t be stupid. Participate and work with the federal government.” The party however chose a different course, which last week ended in disaster.
It now appears that most Republican governors have gotten the message but the Republican state controlled legislatures (many infused with Tea Party loyalists) are seriously lagging behind. A few examples:
Florida: Gov. Rick Scott timidly offered support for a 3 year trial expansion. Florida legislature denied.
Utah: Governor proposed expansion. Legislature denids by adjourning without action.
Wyoming: Governor became a late day advocate. Legislature denied.
Missouri: Governor advocated. Legislature denied.
And then there’s Kansas, whose Gov. Sam Brownback has made some remarkable economic choices that have hurt his state, but he’s still there. He recently became a timid supporter in light of the fact that the state’s own Medicaid funding is “rock bottom” when it comes to coverage. You have to be below 38% of poverty ($9215 for a family of four) in Kansas to qualify for Medicaid. The state’s hospital association just handed the governor an independent study pegging the cost of the state Republican party’s intransigence over the past two years at over $700 million in lost federal funding and an additional 3,400 jobs for the state. Brownback is now “open” to expansion – his Republican led state legislature, not so much.
The Commonwealth Fund just came out with their 2017 Health Scorecard which ranks states based on 40 measures of health system performance. Those denying Medicaid expansion showed significantly less progress in measures of access than participating states. As for overall ranks in hold-out states, here they are. 13 of the 19 are in the lower half of states by performance.
In the wake of the Republican failure to repeal the ACA, reports suggest that some state Republican legislatures have gotten the message. North Carolina, Georgia, Idaho, Nebraska and South Dakota are expected to lead the way.
And how about Kansas? Ask Vicki Scmidt, Republican state legislator and chair of their Public Health and Welfare Committee. She said last week before the vote,“If you can predict what’s going to happen in Washington, that would be great if we could be sure what’s going to happen. But in the meantime, we have to move ahead as a state.” Her Democratic colleague added, “I hope the governor gives the people of Kansas what they want.” Seemingly hedging his bets, the governor last week said “I’ll look at whatever they decide to send and whatever the final product looks like.”
Not exactly courageous, but at this point, we’ll mark that as progress.