Debates about Medicaid expansion betray an underlying fundamental disagreement not only about the Affordable Care Act (ACA) but about the Medicaid program itself. Medicaid, unlike Medicare, lacks the near-universal buy-in to the fundamental value of the program to beneficiaries’ health and well-being. As a means-tested (read welfare-related) program, Medicaid raises concerns and disagreements regarding work (dis)incentives, labor market effects, the “deserving” poor, and how this relates to the construct of health care as a right and a public good.
The Medicaid program serves as a centerpiece of the ACA and of the nation’s health care safety net. The states that continue to oppose Medicaid expansion reveal an important and less acknowledged aspect of this debate: That there remains fundamental disagreement in the United States about whether to include Medicaid as a central and important component of the evolving health care financing and delivery system, or whether system transformation would involve a move away from or elimination of Medicaid, even as a safety net program. Alternatively, how does or might the Medicaid program maintain (or attain) sufficiently broad-based buy-in to withstand wide swings in political control at the federal and state levels?
Variation in ACA implementation has flourished among states. As of August 2014, 27 states and the District of Columbia have adopted a Medicaid expansion as defined by the ACA, four states remain in open debate, and 21 states have rejected such an expansion. Other states, previously opposed to the Affordable Care Act, are implementing programs, under federal demonstration waiver authority, that expand Medicaid coverage for some while substantially altering the rules of participation related to premiums, cost-sharing, coverage type, or patient responsibility provisions.
Debates About the Medicaid Program
The Medicaid program has been subject to study for decades regarding its impact on health care utilization and health, financial stability, and workforce participation. The last decade’s debates around health reform and the Affordable Care Act have added momentum to the scientific study of this program. It has also fueled analysis among think-tanks, commentators, and partisans. The Supreme Court’s 2012 decision, rendering the ACA’s Medicaid expansion unenforceable, re-kindled previously abandoned debates.
Conservative commentators found new, and some longstanding, evidence to oppose a Medicaid expansion. Avik Roy, writing in the National Review, called Medicaid “America’s Worst Health-Care Program” and, in a paper for the Manhattan Institute for Policy Research, cited a range of studies showing poor outcomes for Medicaid members relative to others. Some research suggested that access to care might be improved more substantially by increasing physician payment, rather than expanding Medicaid, a point subsequently used, to that author’s chagrin, in conservative commentary.
Findings from the Oregon Health Insurance Experiment have shown mixed impacts on Medicaid enrollees, leading various experts and commentators to debate the findings. Conservative observers spoke with increased certainty of the program’s failure.
The Galen Institute policy paper asserted definitively that “Medicaid harms the poor.” The New York Times Sunday op-ed columnist Ross Douthat used the opportunity to highlight “What Health Insurance Doesn’t Do.” Others, both liberal and conservative, tried to stake out middle ground, seeking to highlight lessons from the Oregon Health Study.
Meanwhile, other studies have continued to identify various impacts of Medicaid coverage and expansion. Ongoing research assessing the impact of Wisconsin’s BadgerCare program has shown substantial effects on hospitalization and outpatient service utilization.
But, consistent with the Oregon Health Insurance Experiment, Wisconsin’s study also noted increases in emergency department utilization. The Urban Institute, however, has used data from the 2012 National Health Interview Survey to report that Medicaid-covered adults have access to care comparable to those with private insurance. The Milbank Memorial Fund recently published an Issue Brief that reviews these various studies to address claims that Medicaid doesn’t improve health.
None of this substantial work, it seems, has changed the content or tone of the debate surrounding state decisions to expand Medicaid. Pennsylvania’s plan, the most recent Medicaid expansion via waiver by a Republican-governed state, has been criticized by the right as an “ObamaCare Welfare Medicaid Expansion by Another Name” and by the left as cynical ploy by a Governor “desperate for re-election.” Indiana’s Republican Governor Mike Pence expanded Medicaid through the state’s long-standing Healthy Indiana Plan, which he casts as a conservative alternative to Medicaid.
This move received wide approval even among some otherwise opposed to the ACA and Medicaid expansion. Grace-Marie Turner asserted that “Indiana’s Innovative Medicaid Expansion Idea Could Chart A Path For Major Reform Going Forward.” Yet the conservative Washington Times editorialized on “Pence’s sellout on Medicaid expansion in Indiana” and asserted that “There’s nothing conservative about Hoosier’s scheme.”
A Heritage Foundation commentator called Pence’s decision a “disappointment” while The Federalist lamented his version of Obamacare “thinly disguised as a conservative entitlement reform.” Meanwhile, from a different perspective, liberal-leaning Salon discussed the “GOP governor’s laughable attempt to use Obamacare while pretending it’s not Obamacare.”
The Way Forward
Some local communities, mayors, and county administrators, less entrenched in ideological debates, are focused on how to best leverage their limited resources. The Urban Institute’s recent report demonstrates the substantial financial impact of state Medicaid policy on large cities. One Ohio county and its local hospital, not willing to wait for a break-through at the state level, launched its own Medicaid expansion, with the hospital redirecting more than $30 million in county support into a new fund. Some observers expect that such practical concerns will, over time, erode states’ reluctance to expand Medicaid.
Nonetheless, policy debates do not well handle nuances and uncertainty in science. The Medicaid literature offers something for anybody, whatever their perspective. Medicaid will remain vulnerable to political and ideological fortunes until its financial and clinical value is established – and communicated — in a manner that feels more definitive. This requires the research community to go beyond its standard dissemination approaches – engaging in dialogue, particularly at the state level, with decision leaders and the media, acknowledging and respecting the differing perspectives while being perfectly clear where the science offers substantial certainty.
Promising efforts for such engagement are emerging. These include structured partnerships between universities and state Medicaid agencies, something Academy Health hopes to promote through its Learning Collaboratives model. Here at the University of Wisconsin Population Health Institute, our Evidence-Based Health Policy Project operates in formal partnership with a non-partisan service agency of the state legislature to bring forward relevant research and to foster dialogue between researchers and policy decision leaders. And the PCORI Engagement Awards program has funded the National Academy of State Health Policy’s Roadmap to promote the use of research by state policymakers in their deliberations.
Such programs will not themselves alter the partisan differences or other non-science factors that influence policy decisions. They do, however, provide platform for dialogue to bridge the divide between the scholarly and policy conversations. After all, dissemination and implementation science tells us that evidence does not speak for itself: Its take-up and use can benefit from “knowledge brokers” who foster relationships and trust with policy and decision leaders.