Texans Without Health Insurance

Yesterday's last hour of oral arguments pro and con concerning the Affordable Care Act were about Medicaid. In Texas, Governor Perry's "plan" to refuse Medicaid dollars on a states' rights basis would  result in the numbers shown in this bar graph from Progress Texas.

The Justices' questions and comments made clear their disdain for the Governor's position. My own disdain is based on two facts. The current percentage of Texans without health insurance is the highest in the nation (Kaiser State Health Facts). Nationwide, federal tax money is going to pay 93% of the cost of expanding Medicaid coverage, as per the pie chart below from the Center on Budget and Policy Priorities.

After 2022, Texans will be required to contribute more of their tax dollars. I'm not going to try and predict what that dollar amount will be, but the current national average is 57% state tax dollars and 43% federal tax dollars. This is the "coercion" of which Governor Perry speaks. My view is that whatever governor and legislature Texas has over that time span will have financial incentives to provide care for Texans without health insurance, and lets not forget that thirteen states filed an amicus brief with the court supporting Medicaid expansion for their populations, i.e., those state governments do not require "coercion" to take care of their uninsured. Would that my native state of Texas were one of these!

Non-Emergent Care and Medicaid

People insured by Medicaid are quite likely to be drawn to emergency rooms by marketing campaigns such as HCA's "Moving at the Speed of Life" because they often do not have a primary care physician and fewer physicians are willing to accept them because of the low payments Medicaid makes for their care. The fact that they can receive care at a much lower cost to taxpayers in a retail or urgent care clinic is not a factor in their choice of where to go for care when they need it, and they are probably unaware of the relative costs of their care at these various locations. (See yesterday's post, Emergent and Non-Emergent Care: Definitions and Consequences.) Hospitals have no incentive to divert Medicaid patients because they receive a fee for every emergency department service provided. (Kaiser Health News and The Washington Post have collaborated on this subject as well.) Here is a key quote from South Carolina's Medicaid Director Anthony Keck: "Many hospitals are actively recruiting people to come to the ER for non-emergency room reasons. When you are advertising on billboards that your ER wait time is three minutes, you are not advertising to stroke and heart attack victims."

Medicaid is a joint federal-state program, and three states, Washington, Iowa, and Tennessee, have responded by limiting what Medicaid will pay for emergency room services. An especially inappropriate new practice is making the distinction between emergent and non-emergent care at the time of the final diagnosis. A Medicaid patient arriving with chest pain in my example yesterday may be required to pay the full price of emergency room care if the final diagnosis is heartburn instead of a heart attack. Similarly, neither the doctor nor the patient knows at first whether back pain is due to muscle spasms (non-emergent care) or a life-threatening aortic dissection (emergent care).