All Georgia Taxpayers Lose When the State Refuses to Expand Medicaid

There is legislation close to passing the Georgia legislature (it may already be passed by the time this is published) that prohibits “the state nor any department, agency, bureau, authority, office, or other unit of the state nor any political subdivision of the state shall expend or use moneys, human resources, or assets of the State of Georgia to advocate or intended to influence the citizens of this state in support of the voluntary expansion by the state of eligibility for medical assistance under” Medicaid. Its not clear what this legislation actually does, (its not clear it’s authors know what it does), but it could limit the state’s ability to actually run the existing Medicaid program, and perhaps it could prohibit public university professors from answering simple questions about the Affordable Care Act. Is it “advocating or influencing citizens” to report simple facts?

The simple fact is that expanding Medicaid under the Affordable Care Act makes every Georgia taxpayer better off. Costs to every group in the state are higher without Medicaid expansion. In Georgia the cost of care for the uninsured is well over $2 billion dollars annually. That care is more expensive places and often given at the most expensive time (late in an episode of illness). Expanding access to insurance coverage changes the financial burden of the uninsured, the access to care for all, and the health and productivity of Georgians. If the state chooses not to expand Medicaid more than 1.6 million Georgians will lack health insurance coverage in 2014. Georgia taxpayers will continue to bear the costs of care for Georgia’s uninsured while their Federal tax dollars will help reduce those costs for taxpayers in states that are expanding their Medicaid programs.

The Federal government pays the vast majority of the costs of expanding Medicaid in 2014, 2015, and 2016. It pays 100 percent of the costs of care while the state’s share for those three years is increased administrative expenses. After that the states share would gradually rise to 10 percent of the costs by 2021. The Federal government would then continue to pay 90 percent of the costs forever.
The Federal money that Medicaid expansion would draw into a state would generate new economic activity, increase employment, create income and increase state and local tax revenue. Estimates of job creation to do Medicaid expansion in the southeast include 12,000 in Alabama, 44,000 in South Carolina, 50,000 in North Carolina and 70,000 in Georgia. These states see a net gain in employment and economic activity because they have a high number of uninsured who could gain coverage under Medicaid expansion. If these states opt out of Medicaid expansion they give up that income and the tax revenue generated by it.

Failure to expand Medicaid puts employers in the state at greater risk. Not only will they have a less healthy, less productive workforce, they are more likely to face a tax penalty if they do not offer affordable health insurance to their employees. Under ACA starting in 2015 employers who have workers who are eligible for a subsidy in the exchange pay a “shared responsibility” tax. Without Medicaid expansion there are more workers who would be eligible. Jackson Hewitt estimates that those costs to employers could range from $71 million to over $107 million in Georgia

For Georgia the argument that the state government just can’t afford it is difficult to reconcile with both the increase in state revenue and the savings to a whole host of state programs resulting from Medicaid expansion. Medicaid expansion would replace behavior health costs paid by the state, decrease criminal justice costs, decrease public health costs, and increase direct revenue from assessments on health care providers.

Expanding Medicaid would also increase access to care for all Georgians. Many parts of Georgia have been identified as Medical workforce shortage areas. Those mostly rural areas lack the resources necessary to attract and retain physicians and other health care providers. Medicaid expansion increases the resources available for those areas.

It has been argued that the Medicaid program is broken and there is no sense putting more money into a broken program. There are numerous ways the Medicaid program could be made better including changing reimbursement mechanisms and levels, measuring and rewarding the quality of care, and incentivizing healthy behaviors. All of these elements are under control of the state. Its not clear why Georgia can’t use the resources that Medicaid expansion would give them to address any flaws in the Medicaid program.

The argument has been made that Medicaid would be a better system if the Federal government would change the financing to block grants. Under the current (and expanded) Medicaid program the Federal government matches state expenditures. The block grant recommendation is made as a way to address perceived Federal deficits issues. It only works if less money is sent to the states. If states are feeling the pinch of Medicaid expenditures under the current system its difficult to understand how they would be better off with less money.

The whole health care delivery system is a broken system. That of course is underlying rationale for the Affordable Care Act. Health care cost inflation cannot be slowed by simply decreasing eligibility to public programs or reducing provider payments. The incentives in the health care market must be altered to give providers, consumers, and payers incentives to improve health cost-effectively.

Given the importance of Medicaid expansion as a piece in the puzzle of developing a sustainable health care system it seems unlikely that some future Congress would defund the program. Future Congresses will be made up of Senators and Representatives from the states who expanded Medicaid.

It is ironic that many of the same voices calling for the Federal Government to block grant the Medicaid program also voice this concern about Medicaid expansion. A block grant by design would shift more of the costs to the state.

The politics of its enactment aside, decades of analysis, experimentation and debate generated a consensus around the policies that underlie the Affordable Care Act. Any health reform that preserves the private sector role in health care delivery would resemble the Affordable Care Act. Medicaid expansion’s role in that reform is to provide a seamless path from public to private coverage as family incomes grow.

But I ain’t advocating (with sincere apologies to Fats Waller)
(Mutter to the tune of Ain’t Misbehaving)
No one to talk with
all by myself
No one to talk with,
but the facts are on the shelf
Ain’t advocating’,
I’m just stating the facts

If we don’t expand Medicaid
Fewer hospitals get paid
Ain’t advocating’,
I’m just stating the facts

Up to 70,000 jobs won’t be there
More folks without access to care
And not just low income, all will pay the tax

Still our taxes go elsewhere
To Georgia taxpayers its just not fair.
Ain’t advocating’,
I’m just stating the facts

Kolstad, Jonathan T. & Kowalski, Amanda E., 2012. “The impact of health care reform on hospital and preventive care: Evidence from Massachusetts,” Journal of Public Economics, Elsevier, vol. 96(11), pages 909-929

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