The Patient Protection and Affordable Care Act (ACA) is the civil rights legislation of our generation. After decades on the Democratic platform, this monumental law has been born into the public, warts and all. While Republicans pursue lawsuits that would limit or even repeal the ACA, the sometimes-bumpy rollout continues to gain traction. Surely, this imperfect law will take many modifications to optimize its effectiveness--Medicare took over 20 years to work properly--but increasing success makes it unlikely that the ACA will be revoked.
Last year over 15 million Americans purchased insurance through the Marketplace and hospitals—especially in states that expanded Medicaid—saw a monumental drop in uncompensated care. These results have grabbed the attention of Republican governors whose states left Medicaid money on the table after the U.S. Supreme Court ruled that a mandatory expansion was unconstitutional.
Montana is one of the 23 states that has not taken the Medicaid expansion, leaving roughly 70,000 people (mostly childless adults) uninsured. Those folks are still using medical services though, and someone has to pay. Without the expansion, these costs are passed on to consumers (in the form of higher insurance premiums), hospitals (emergency rooms are hit the hardest), and government (consumers again, here as taxpayers). Indeed, in states that refused the Medicaid expansion, disproportionate shares (payments made by the federal government for Medicaid shortfalls) are reduced; meaning hospitals are getting even less relief than they were before the ACA.
An August 2014 cost/benefit analysis by the Urban Institute contends that Montana would have spent $194 million dollars over 10 years of expansion, but instead will lose $2.1 BILLION dollars of funding over the same time period, a figure that doesn’t include the hospital reimbursement which would total another $1.1 billion dollars. With promoters of the law saying it will improve personal and public health and the statistics saying the law is cost effective for government, it seems like a bipartisan win for our upcoming legislature to accept the Medicaid expansion without delay.
However, mounting evidence that the ACA is good for people and good for business does not drive a state’s decisions to expand. No, motivations for expanding or not expanding access to affordable health care come from somewhere other than logic. Although it is obscured to most, this decision will be influenced by Martin Luther, who taught that hard work earns eternal salvation, and John Calvin (picture, below), who preached that wealth is theresult of God’s grace. Sprinkle it with capitalism, wrap it in political jargon, and we get a morality that makes it easy to justify denying health and prosperity to vulnerable populations.
None of these worldviews are evil unto themselves, but it behooves us to discover the invisible knowledge that lurks inside our public policy if only so we can say firmly that we reject models of society based on the fundamental exclusion of some human beings. Republican legislators have said they voted against the Medicaid expansion in 2013 because they think it will cost too much money and they do not trust the federal government to keep its promise to foot most of the bill. However, look closer and you will see an emotional response about what we owe each other as human beings existing in community.
There were also legislators in the 2013 session who voted against House Bill 623 because it was a poor compromise, similar to the Arkansas model of expansion, which uses the federal funds for vouchers with which insurance may be bought from private insurance companies. With bill drafts regarding health care emerging from both sides of the aisle for 2015, it is likely that Montana will see this option again.
Ironically, the Arkansas model costs more money to administer than normal Medicaid. It will be interesting to see who comes forward in favor of this option, but we need not become resigned to it. Governor Steve Bullock has hinted he intends to bring the expansion forth. In the months to come you will see the Montana Hospital Association andinsurance companies, among many others, speak in favor of Medicaid expansion. Most will do so because of the cost/benefit analysis, not the human costs that people are paying with their lives. We can tip the dialogue when we muddle through our resistance and take a stand for the right to health for all people.
The Affordable Care Act has visionary potential for our communities, which includes financial provisions for public health, prevention, and evidence-based care. It also funds community health clinics, the National Health Service Corps, and maternal, infant, and early childhood home-visiting programs. This potential is crippled when those who need these services most do not have access to care because they cannot afford it.