So far, Texas has resisted Medicaid expansion with its siren call of “free” federal money and “free” insurance. The San Antonio-Express News Editorial Board is now urging Texas to rethink Medicaid expansion (“Why it’s time for expansion of Medicaid,” July 29).
But does Texas really want to rethink the Lone Star State out of the frying pan into the fire?
Insuring people is not why we have a health care system. The purpose is to get timely care to the most people at a price we all can afford. Despite its high uninsured population, Texas provides the best access to primary care and the lowest wait times in the country. Ironically, the state with the lowest uninsured rate, achieved by expanding Medicaid, New York, has poor access to primary care and excessively long wait times.
Conflating health insurance with health care is a common cognitive mistake. Those with insurance often do not get care, at least not in time. Despite having Medicaid coverage, 752 residents of Illinois died while waiting for care. According to an internal VA audit, “307,000 veterans may have died waiting for care,” despite having government-issued insurance. Such death-by-queueing occurs in Canada, Great Britain, our VA system and the Medicaid program. In the 85th Texas Legislature, dozens of Medicaid recipients and advocacy groups testified about inadequate services provided by Texas Medicaid.
Being uninsured does not prevent people from getting care. With the Emergency Medical Transport and Labor Act of 1986 in effect, hospitals must, by law, provide care to all who present themselves regardless of whether the patients have insurance. Some say outcomes in Medicaid patients are no better than the uninsured and may be worse.
Expanding Medicaid under the ACA will not get more Texans in the doctor’s office. In fact, less than half (47 percent) of Texas doctors are willing to accept new Medicaid patients because of the huge bureaucratic burden dealing with government-contracted insurers and Medicaid’s low reimbursement schedule.
It is outrageous to attack Texas for leaving “billions of federal dollars on the table.” First, there is no such thing as “federal dollars”— those are taxpayer dollars, and a lot of them come from Texans. Second, money comes from Washington to the states through a dollar-matching program calculated according to Federal Medical Assistance Percentages. A state gets at least $1 for every dollar it spends. Poorer states such as Mississippi can get as much as $3.11 for each $1 spent, not the 9-to-1 claimed by the editorial. This scheme encourages a state to spend as much as possible, the exact opposite of what people want from politicians.
Before the Express-News recommends expanding Medicaid, it should check out what happened when Texas’ neighbor New Mexico expanded its program for the medically vulnerable.
The New Mexico Legislative Finance Committee calculated that the Land of Enchantment could receive as much as $3 billion in additional federal dollars if it expanded its Medicaid program per Obamacare. New Mexicans did sign up in droves for free coverage, and by 2017, 41 percent of the entire state population was enrolled. The state did indeed receive approximately $3 billion from Washington. The cost, however, for compliance with the new ACA mandates cost $3.4 billion.
With a program shortfall of $417 million, New Mexico Medicaid had no choice. It was forced to lower its already low physician reimbursement. Fewer doctors could afford to accept new Medicaid patients. The effect of Medicaid expansion was to increase the number of insured persons and, at the same time, reduce access to care, not just for the newly insured but for all Medicaid enrollees.
Rethink Medicaid? Sure, Texas should rethink the failing program, but expanding Medicaid via the ACA is the last thing we need. It was federal control of what was supposed to be a state-administered program that got Medicaid into its current troubles. Increasing Washington’s role is like pouring gasoline on a fire. To fix Medicaid, Texas needs to go the other way: deregulate and return administrative authority to the state level, where it belongs.
This commentary was originally featured in the San Antonio Express-News on August 6, 2018.