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Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…[1]” Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why.

Please understand that refusal to expand Medicaid is not about state expenditures. Over the ten years, 2013-2022, every state would gain far more than it would spend for expansion [2]. Were all states to opt-in, the total ROI for the states combined would be almost 10,000% ($8 billion state expenditures in return for $800 billion federal).

Empirically health is associated with income, so if you’re poor you’ll likely have worse health. Also it’s well known that chronic conditions are often comorbid, that if you have a chronic disease, you probably have more than one. Additionally, chronic disease is a major contributor to total health care costs. Here’s a graph of percentages of two chronic diseases, coronary heart disease and diabetes, across the 50 states.

MedaidChronicAggregated at the state level there’s a strong relationship between these two morbidities. Furthermore there’s a clear association of disease prevalence with poverty: the average poverty rate in the lower left quadrant defined by the median lines is 11.7%, whereas the average rate is 17% in the upper right quadrant.

There are 14 states so far where the political deciders have opted out of expanding Medicaid related to health reform [3]. Ten of those 14 clearly have worse population health (they are in the upper right quadrant). For the citizens of those states, it’s not just about being poor and not having access; it’s about being poor and less healthy, and not having access.

What is it here that voids accepted creeds of good works (e.g., the Golden Rule or Matthew 25:35-46)? I contend it stems from the view that the market rules and everything has a price, that competition is the wherewithal, the belief that we’re totally self-reliant and all that’s worthwhile derives from great men so that an unequal society is a good society. If those are a decider’s convictions, especially the great men part, then a preferred health policy would omit the weak: Surely one shouldn’t provide for them; that would just weaken them further as a people. I conjecture these are the notions that support the political decisions which repudiate the common good.

Frank de Libero is an independent statistical consultant oriented toward policy and strategy. He blogs regularly at Letting the Data Speak, where this post originally appeared.

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20 Responses for “Letting the Data Speak: On Refusing Medicaid Expansion”

  1. BobbyG says:

    “the view that the market rules and everything has a price, that competition is the wherewithal, the belief that we’re totally self-reliant and all that’s worthwhile derives from great men so that an unequal society is a good society.”
    __

    What is the moral purpose of “markets”? Are they simply amoral? That a winner-take-all ethos by the most adeptly rapacious is OK?

    What is the very purpose of human civilization? A rule of law?

    Hint: it is not “self-evident.” We get to DECIDE such things.

    Also, when we speak of the “moral,” eyes roll, as if the “ought” stuff is so subjective and nebulous.

    It is not. It could not be more important.

    • Jardinero1 says:

      Markets are where willing sellers and willing buyers meet without coercion. Without coercion, willing sellers and willing buyers agree on the quality of the good and the price. If they fail to agree, they may walk away from one another.

      Markets serve no moral purpose, they serve an expedient.

      • BobbyG says:

        That’s fine as a broad assertion. It assumes that all markets are of equal moral import.

        When you have a life threatening illness or have been seriously injured, you are no mere “consumer.”

        “Markets serve no moral purpose”

        We will just have to disagree on that.

  2. Jardinero1 says:

    There is a logic fail here.

    The graph tells you only about the present. At present, and for the last forty five years, all states have been reimbursed for Medicaid at the same level. What this graph tells you is that, after forty-five years of Medicaid, there is a very wide variation in the incidence of diabetes and CHD. Since forty-five years of Medicaid has done nothing to narrow the variation, and incidence rates of diabetes and CHD have risen since the inception of Medicaid, and by your own admission, these diseases are very closely correlated to poverty rates; there is no reason to think that still more Medicaid will close the gap in incidence rates, much less to reduce them overall.

    Maybe the solution is something other than Medicaid.

  3. Vik Khanna says:

    With the exceptions of Maine and Pennsylvania (which is culturally and politically a southern state stuck above the Mason Dixon Line), all the refusing states are in the south. In fact, they form the line of states known as the obesity belt, where poor health habits are a deeply ingrained way of life.

    “Fixing” the chronic disease crisis in the South (if that is even doable) means taking a long hard look at things like school curricula and food programs, neighborhood development, food and lifestyle messaging and marketing, and the roles played by churches and employers. There is nearly linear relationship between healthy lifestyle habits (and, thus, disease risk) and education and income. But, it’s much harder to ensure that people complete high school and learn a trade or go to college than it is to give them a Medicaid card.

    Expanding Medicaid is a band aid on communities that need to have a major operation on their health culture. But, the problem, I fear, is that most people don’t care to work to change the trajectory of their health lives, and many simply cannot afford to do so. Maybe all we are left with, then, is to expand Medicaid and hope that doing so elevates some people’s health lives and that it becomes an investment in human capital that eventually returns to us all in the form of educational or employment achievement. I’m not holding my breath.

  4. I want to add a few facts about Medicaid and the expansion.

    Medicaid as it currently exists is primarily for children, pregnant women and, long-term care for adults with severe disabilities. Medicaid is managed by the states within federal guidelines. Still what states offer vary a lot. Currently childless adults who are not severely disabled do not qualify in most states. In fact, in a majority of states adults with children effectively don’t qualify for Medicaid, just the children. The expansion of Medicaid under health reform is meant to change that within eligibility constraints.

    A primer by the Kaiser Commission on Medicaid is available here, http://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf. On page 10 of that document is a thematic map showing eligibility for working parents by state. The ten states in the upper right quadrant of this post have Medicaid income eligibility at some threshold below the poverty level ($19,530 for a family of three); five of those states require incomes less than half that for consideration, less than $10,000 a year for a family of three. I spend more than that in Seattle just for shelter. Most adults over the history of Medicaid, poor or not, have not participated in Medicaid. The Medicaid expansion is about changing that for people in need.

    ..Frank

    • SteveH says:

      “Most adults over the history of Medicaid, poor or not, have not participated in Medicaid. The Medicaid expansion is about changing that for people in need.”

      Thank you for making this very important point clear.

  5. Walter Valliere says:

    “Ten of those 14 clearly have worse population health (they are in the upper right quadrant). For the citizens of those states, it’s not just about being poor and not having access; it’s about being poor and less healthy, and not having access.”

    As presented, you imply that if the 14 states you reference opted-in, the poor would be more healthy and have better access. You forgot to mention that many states that opted-in to this regulation have equally bad if not worse results. This article seems to lack objectivity.

    • Peter1 says:

      “You forgot to mention that many states that opted-in to this regulation have equally bad if not worse results.”

      Walter, having health care is not the same as having health. But would you deny them just because we can’t seem to break them of bad habits? I guess YOUR doctor should refuse to treat you if your ailment is due to bad habits.

      • Walter Valliere says:

        Your reply is ad hominem. I still contend that the article lacks objectivity.

        • Peter1 says:

          “Your reply is ad hominem.”

          Really, where is the character attack or prejudice?

          You lump access and better health in an argument about better health. Surely getting access to health care is better access than no access.

          You’re being picky about a non issue. Does the rest of the population’s access give us better health, depends. Getting a kidney transplant is better health, curing obesity and diabetes much more illusive, yet we don’t justify better health for wealthier populations based on outcomes – just access to treatment.

          Fixing the poor’s state of health is as difficult as fixing the rest when junk food, high salt, high fat, high sugar and little exercise is the culture.

  6. Bob Hertz says:

    What all the refusing states share in common is a determination that they will not be a comfortable place for poor people to live.

    Much less migrate to!

    The economic strategy in these states is to export poor people and minorities, while simultaneously attracting wealthier retirees.

    Having no state income tax is a prime part of this strategy.

    Michael Lind covers this in several articles, such as ‘Uninsured Like Me.’

    (incidentally, I discussed in John Goodman’s conservative blog, and several respondents really lit me up.)

    Bob Hertz, The Health Care Crusade

  7. Bob Hertz — thank you. I wasn’t aware of the Bob Lind article or the strategy you mention. Still it’s plausible just based on my interactions with people. There’s still a lot of anti-black sentiment, and not just in the South.

    Walter, keep in mind that opting-in is for future Medicaid expansion. It doesn’t begin until 2014.

    ..Frank

  8. bob hertz says:

    Thanks for the comment Frank.

    The general feeling in the USA is that we should do everything for the elderly, because in general they have worked all their lives. (people with no jobs often do not survive to be elderly),

    But we are much stingier as a nation about helping younger persons on welfare. This group is much darker than the elderly, you just cannot get away from this.

    Listen to any Tea Party speaker compared ‘earned benefits’ like Medicare to ‘welfare’ like Medicaid. This is fiscal nonsense but it has a lot of emotional resonance,

  9. legacyflyer says:

    Several points:

    1) As the recent Oregon Study shows, having Medicaid does not necessarily lead to better health.

    2) I have heard that the state share of the cost of expanded Medicaid goes up each year and does become a significant issue in later years. (I would appreciate more information on this point)

    3) The idea that if something is from the Federal Government, it is “free” is the cause of “Bridge to Nowhere” in Alaska and the “Lawrence Welk” Memorial in North Dakota – both constructed primarily with Federal money.

  10. Tom Leith says:

    > Please understand that refusal to expand Medicaid is not about state
    > expenditures. Over the ten years, 2013-2022, every state would gain far
    > more than it would spend for expansion [2]. Were all states to opt-in, the
    > total ROI for the states combined would be almost 10,000% ($8 billion
    > state expenditures in return for $800 billion federal).

    Of course is is about expenditures — I have to extract an additional $8 billion from non-medicaid participants in order to spend the promised $800 billion on medicaid participants. So the return on my “investment” accrues to someone else, meaning it is not an “investment”, I don’t like it and I tell my state rep who really wants to keep his job. Voila! No medicaid expansion because it IS about “state expenditures” which always begin as “state taxes”.

  11. Walter Valliere says:

    @Tom Leith,

    Indeed it is about money and our lack of it. Medicaid Expansion is a political ploy to gain political support, particularly among the uniformed voters.

  12. Walter Valliere says:

    @Peter1

    Just catching up. here change the subject and go after me: “I guess YOUR doctor should refuse to treat you if your ailment is due to bad habits.”

    Now, I am a basic scientist and mathematician. I encourage those in non-scientific and mathematical fields to include and use all of the data before offering interpretations. Interestingly, I don’t see this discipline in social and political writings, which might partially explain how it is the nation is spending far more money than it has on unproven, but politically-oriented, “solutions to medical care when the simple response is to reduce services and spend less.

    And Frank, you are absolutely right: the magic year is 2014. A political plan exists with rational thinking about how this new bureaucracy will be funded. I view it as First Year arithmetic: John has $1. Mary has three apples that sell at $.50 each. How many apples can John buy? Using the view (I can’t call it thinking), John get Mary’s three apples the $1 allows him to buy a dozen future Mary’s apples. Give me a break!

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