No Medicaid expansion could create health care gaps

WASHINGTON — States that have not expanded their Medicaid programs as part of the Affordable Care Act risk larger-than-ever gaps in overall health between residents of their states and those that have expanded Medicaid, a report released Wednesday shows.

Nine of the top 13 states in overall health have expanded Medicaid, while three in the lowest 12 have not expanded, according to the report by the Commonwealth Fund, a non-profit group studying U.S. health care.

"There is money on the table for every state with the potential to close the steep geographic divide," said Commonwealth's senior vice president, Cathy Schoen. "Notably, 16 of the states at the bottom half of the distribution have decided not to participate in Medicaid expansion."

Of the top 25, eight states have chosen not to expand.

Researchers also fear that those discrepancies could increase as some states make gains "through Medicaid and high-quality private insurance choices in the new marketplaces, while other states lag," according to the report. They found as much as an eight-fold difference in measures in the better-performing states than in the poorly performing states.

About half the states chose to expand Medicaid to people within their states who fall below 138% of the federal poverty level — or $32,913 for a family of four. Other states, all with Republican governors, chose not to expand, creating a double hit because people who make less than 100% of the federal poverty level are not eligible for subsidies to help them buy health insurance through the exchanges.

Governors have argued that participating in the expansion would increase the federal deficit, with Alaska's Gov. Sean Parnell saying, "The Obamacare Medicaid expansion comes with skyrocketing increases — billions with a 'B,'" as he announced Alaska would not expand.

Three states with Democratic governors have had their moves to expand stymied by state legislators, and Sen. Ted Cruz, R-Texas, said earlier this month that expanding Medicaid would "worsen health care options for the most vulnerable among us" at an event supporting Texas Gov. Rick Perry's decision not to expand Medicaid.

Commonwealth's rankings are based on 42 separate measures, including the number of insured to the number of people who smoke to how many are missing six or more teeth, using 42 measures to determine who fared the best.

The report does not include any of the changes made because of the Affordable Care Act. At least 8 million Americans signed up for private health insurance through the health exchanges during open enrollment from Oct. 1 to March 31, while another 3 million enrolled in Medicaid or the Children's Health Insurance Program.

The number of uninsured adults fell by 5.4 million between September 2013 and May 2014, according to a Urban Institute report released Tuesday. Researchers surveyed people to try to determine how many people who signed up for insurance through the exchanges had not been insured before. The researchers also reported that more people are expected to sign up in 2014, both through Medicaid and when open enrollment begins again in the fall.

The Commonwealth report found that 29% of adults were uninsured in Florida, New Mexico and Nevada, as well as more than 30% in Texas, said senior scientist and co-author David Radley. In the states with the highest rates of uninsured, about 19% of adults went without needed care, he said.

"If people can't get in the door, they can't receive high-quality care," he said.

Utah, Montana, Idaho, Arizona, New Mexico, South Carolina, Florida, Texas, Georgia, Nevada, Louisiana, Arkansas and Mississippi ranked worst in the nation for access and affordability, according to the new report. Arizona, New Mexico, Nevada and Arkansas have expanded their Medicaid programs.

While Colorado, Maryland, New Hampshire and New York improved in most areas, such as not delaying care or having patient-centered care, most states saw no improvement whatsoever in most areas, researchers found. Mississippi ranked in the bottom 25% in each category, while Louisiana, Oklahoma and Arkansas were in the bottom 25% in all but one measure.

The top-performing states — Minnesota, Massachusetts, New Hampshire, Vermont and Hawaii — have maintained those rankings for several years, researchers found.

Some of Massachusetts' success may be because they created an "individual mandate" under former governor Mitt Romney, requiring everyone to buy health insurance while providing better access to it.

"Massachusetts' experience with insurance coverage expansion suggests that cost-related barriers to care should ease for individuals and families who gain coverage under the Affordable Care Act," researchers wrote.

But the new law could also expand gaps in who has good health care and who does not, the authors found.

"It is possible that geographic disparities in performance will widen, and health care inequities within states worsen, if such health system reforms and innovations are not evenly spread across states," the authors wrote.

But improvements are possible, the report found, noting that even the leading states have room to get better.

Schoen said the researchers hope to see the same kinds of gains they've seen in children expand to adults. But children's health advanced because of state and federal programs aimed at improving their nutrition or making sure they had access to vaccinations, as well as providing insurance through CHIP.

Commonwealth compared access and affordability; prevention and treatment; avoidable hospital use and cost; health lives; and equity.

Almost all of the states improved in areas that have seen heavy advertising or in increase of resources, such as childhood immunizations, safe prescriptions for the elderly, avoidable hospital admissions and deaths from cancer.

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