Medicaid expansion: The cost of doing nothing

By Dr. William Woodhouse

“I’m seeking no expansion of those benefits. Instead, I’m asking Director Armstrong to lead an effort to flesh out a plan for changing Idaho’s system with an eye toward the potential costs, savings and economic impact. I hope to return in 2014 with specific proposals based on that work….”

—Gov. Butch Otter, State of the State address, Jan. 7, 2013

For the working poor of Idaho without health insurance, one more year is a very long time. Idaho elected officials face an ideologically unpalatable option under the Affordable Care Act, to expand Medicaid coverage to the working poor. However, while they defer action, it is critical that we do not lose sight of the ongoing price being paid for doing nothing. The fact is that with each day that goes by, tens of thousands of uninsured Idahoans, who earn minimum wage doing our most basic and necessary work, are at increased risk for going bankrupt, living sicker and dying younger.

A study of bankruptcy by Himmelstein et al published in Health Affairs in 2005 found that over half of the bankruptcies in Idaho are directly related to health care costs. In a 2009 study published in the American Journal of Public Health, Wilper et al concluded that nearly 45,000 adults in the United States die each year because they are uninsured and cannot access the health care services they need. But perhaps most relevant to this issue is a study published just this past July in the New England Journal of Medicine, which looked at four states that had chosen to expand Medicaid coverage to previously uncovered populations. What they found was that for every 176 people who were newly-covered by Medicaid for a year, one person did not die.

Of course most Idahoans, many of whom survive day-to-day on among the lowest per capita incomes in the US, do not need a lot of academic data to know all this. They live it every day. They see the flyer on the feed store bulletin board announcing the latest fundraiser being held to help one of their neighbors make ends meet in the face of illness and overwhelming health care costs. They drop their hard earned change through the slot in the coffee can on the convenience store checkout counter. They read the fundraiser announcements in the newspaper and show up for the spaghetti feeds, barbeques, raffles, benefit concerts, pool tournaments, silent auctions, rodeos, bake sales and 5K fun runs.

It’s a folk remedy of sorts for a sick health care system. They have to do something. It appears that they have given up hope that those in power will fix the problem. Like most folk remedies it is heart felt, yet woefully inadequate in the face of the enormous costs.

Do the math. If the Idaho legislature fails to expand Medicaid to the approximately 80,000 individuals who would be newly-eligible under the Affordable Care Act, over 450 of them will likely die as a result. Many more will lose their life savings and live sicker. The decision to expand Medicaid to the working poor of Idaho should not be held up by the separate, but important, need to reform Medicaid to promote primary care, prevention and healthy life styles. It is unlikely that Idaho will ever see a more affordable opportunity to provide for the otherwise inaccessible health care needs of this essential group of people.

Dr. William M. Woodhouse is the associate director of the Family Medicine Residency Program at Idaho State University.