Uninsured pay the price for ACA reform failure

On Election Day, Maine holds a popular vote on whether to expand Medicaid. No other state has done that.

The expansion would cover an estimated 70,000 people who don’t have health insurance. The decision embodies two key elements of most government actions: there’s no free lunch and nothing is decided once and for all.

After the Affordable Care Act was passed, the Supreme Court ruled that the federal government could not force states to cover more people under Medicaid, even when the feds paid about 90 percent of the cost. The ACA would have withdrawn existing federal payments if states did not accept expansion.

That decision left it up to the states to decide on voluntarily accepting expansion. Though 31 states plus D.C accepted, 19 did not. Maine resisted expanding its Medicaid, called MaineCare, the only northeastern state to reject increased coverage.

The Maine Legislature voted six times to accept the expansion, but Gov. LePage vetoed the bill each time. The issue comes to the voters because of a citizen initiative, which could not be vetoed.

LePage not only sees expansion as “welfare,” but dislikes its budget impact. It would cost the state less than $55 million, and each state dollar would bring $9.63 in federal dollars. Under the non-controversial highway referendum, Question 3, each state dollar would bring $1.10 from the feds.

Without the expansion, people who would have been eligible must continue getting haphazard medical care by relying on emergency rooms. The cost of their care is rolled into hospital costs and recovered in higher charges. Insurance premiums rise to handle the increases.

All the money comes out of people’s pockets, but we have little idea how much of the state spending would be offset by lower hospital costs and insurance premiums. LePage looks at the state budget not the individual’s wallet.

But increasing the number of people with health insurance coverage inevitably costs more. That’s why the ACA raised taxes on the wealthy. Still, there’s no way to be sure just what the net cost is.

So the vote comes down to whether Mainers want to risk a higher net cost to help more of their neighbors get better medical care. That is a classic political decision, involved in every budget action in Washington or state capitals.

Does the community, through its government, want to pay more to do more? If keeping the budget down is the highest priority, as it is for LePage, then his answer is “no.” Now it’s up to voters to give their answer.

This kind of decision must be made over and over on everything done by any government, from military spending to medical care. Only rarely do the voters find themselves deciding the answer.

LePage has another concern. Once Medicaid is expanded, how sure can we be that the federal government will keep up its end of the bargain? Perhaps years down the road, it will decide to change the funding formula, leaving states to pick up more Medicaid costs.

To avoid that risk, voters would have to turn down Medicaid expansion. This a reasonable issue to consider.

It’s like current proposals for tax “reform,” with cuts proposed that would reach out at least 10 years. No Congress binds another on most matters, so tax cuts could well be revoked sooner than promised.

In a democracy, people get to change their minds, especially in changed circumstances. If worry about possible change were allowed to control, not much would happen.

Still, it is worth worrying about programs like Social Security, Medicare and Medicaid that weigh heavily in the budget, but whose costs are driven by participant eligibility not budget priorities.

The answer may not be to deny people help they need because of such worries, but to address the underlying problem directly and comprehensively. Touching these programs is considered the fatal “third rail” of politics. Most likely, the only solution will come from a nonpartisan effort.

When benefit payments are guaranteed, providers and insurers may be tempted to use the system to boost their revenues. What decisions need to be made to limit the growth in costs?

Better ways of determining eligibility and improved protection against cheating is essential. But also essential would be some method of regulating costs of quasi-monopoly health care. Now that repealing the ACA has failed, it’s time for reform.

Maybe that’s what critics will now accept. But much-needed health insurance action should not use the ill, lacking insurance and access to affordable medical care, as hostages to force reform.