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January 26, 2015

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j. patrick coolican:

Medicaid expansion should be a no-brainer for Nevada

J. Patrick Coolican

J. Patrick Coolican

If Nevada doesn’t expand its Medicaid program, one result is that people will die. That’s the stark conclusion we can draw from a New England Journal of Medicine study, which found that in states that expanded their Medicaid programs, mortality rates declined 6.1 percent, with the largest declines among minorities and older adults.

So, if you’re against Medicaid expansion, you’re for a higher mortality rate, especially among our most vulnerable populations. Provocative? Yes, maybe even demagogic, but no less true for being so.

The reality, of course, is that when it comes to health care policy, we must make trade-offs that are both cruel and necessary. We’d probably also have a lower mortality rate if we stuck a paramedic in every home, but we’re not going to do that because the costs would far outweigh the benefits (though I suspect the firefighters’ lobbyists will propose this at the next legislative session.)

When it comes to expansion of Medicaid — the federal-state health insurance program for the poor and disabled — the benefits far outweigh the costs.

The federal government would pay 100 percent of medical costs for newly eligible Medicaid recipients through 2017. By 2020, federal funding would drop to 90 percent.

Nevada currently has one of the stingiest Medicaid programs in the country; Medicaid covers just 12 percent of Nevada adults, the lowest in the country, according to the most recently available data from Kaiser State Health Facts.

According to Gov. Brian Sandoval’s spokeswoman, Mary-Sarah Kinner, there are 308,000 people on Medicaid in Nevada, with natural case load growth expected to push that to 334,000.

The state expects an additional 49,000 Nevadans will enroll in Medicaid as a result of the Affordable Care Act’s individual mandate that requires everyone to get some kind of insurance. (These Nevadans are currently eligible for Medicaid, but haven’t enrolled.) This will cost the state $60 million.

Kinner said Nevada Check Up (Children’s Health Insurance Program) is expected to increase by 20,000 children. Again, these are eligible children who haven’t been signed up. This will cost $11 million, which is a pittance compared with the benefits of delivering basic health care to 20,000 children.

The federal Medicaid expansion will add an estimated 72,000 Nevadans to the Medicaid program by the end of the next biennium; there would be administrative expenses associated with the expansion, though the state hasn’t determined the cost yet.

Some will argue that this attempt to provide everyone access to basic medical care is an example of cradle-to-grave welfarism. Indeed, in one of the riveting moments of the Republican presidential primary debates, CNN’s Wolf Blitzer asked a hypothetical question about someone who chooses not to purchase health insurance and then gets in an accident and requires care: “Are you saying society should just let him die?”

Some in the crowd yelled, “Yeah!”

It’s an interesting debate, whether basic medical care is a right or a privilege, at least for people who read Ayn Rand novels. (I loved “The Virtue of Selfishness” when I was 17. In retrospect, it was age-appropriate.)

But this question of right vs. privilege has to some degree been answered, not just by other industrialized democracies, which guarantee some basic care, but also by the United States.

The Emergency Medical Treatment and Active Labor Act, signed in 1986 by the Great Man himself, President Ronald Reagan, was passed “to ensure public access to emergency services regardless of ability to pay,” notes the Centers for Medicare & Medicaid Services. Private hospitals had been engaging in what’s called “patient dumping,” sending uninsured sick people to public hospitals. The law required hospitals that take Medicare funding — which is 98 percent of them — to screen and stabilize the sick and injured, regardless of ability to pay. Through regulations and legal rulings, the scope of the law has expanded, according to Dr. Joseph Zibulewsky, in a paper in the Baylor University Medical Proceedings.

The upshot is that our hospitals treat a lot of patients without insurance. Nevada’s 17 major hospitals, meaning those with more than 100 beds, absorbed $767 million in uncompensated care in 2011. Some of that is due to reimbursement rates for Medicaid and Medicare that are lower than the cost of providing care; but some of it is from treating people without insurance and no means of paying.

Although patient dumping is illegal, our sole public hospital, University Medical Center, bears the biggest brunt of those costs.

Discussion of the Medicaid expansion in Nevada thus far seems to have missed this point — that expanding Medicaid, with mostly federal dollars, would lighten the burden on UMC and, thus, lighten the burden on county taxpayers.

As Brian Brannman, the CEO of UMC and a retired Navy rear admiral, told me in a recent interview, UMC provides between $200 and $250 million in uncompensated care. In the emergency department, between 20 and 25 percent of the patients have either Medicaid or Medicare, which is the government’s socialized insurance program for people 65 and older. Government reimbursement rates aren’t enough to cover the hospital’s costs, but patients on government insurance are better than the alternative. One quarter of emergency department patients are “self-pay,” which means they have no insurance and either pay cash or pay nothing. The hospital recoups just 6 percent of those patient costs, Brannman said.

“We’re a black hole, insofar as we have to provide care, and we often won’t get paid,” he said.

The hospital produces significant revenue to make up for all that uncompensated care, but it still has a $60 million operating loss. County taxpayers own UMC, which means we eat that loss.

Brannman is urging policymakers to strongly consider expanding Medicaid.

Maura Calsyn, associate director for health policy at the Center for American Progress, notes, “Everything in the entire system is interconnected. If there’s pressure in one place, they’ll look to other places where they can actually receive payments, meaning private payers.” In other words, if they can’t get paid by some, prices go up for everyone else.

If some of those non-paying patients were enrolled in an expanded Medicaid program, the hospital would lose less money, and county taxpayers could get some relief.

Finally, here’s another reason to expand Medicaid: Although it won’t be free for state taxpayers, it will lead to an influx of federal money — $1.8 billion between 2014 and 2019. I don’t know about you, but I feel like our economy could use a $1.8 billion infusion. And given our mediocre medical care here, health infrastructure seems like a good place to invest federal money.

Health care accounts for about 18 percent of America’s gross domestic product. In Nevada, as my colleague David McGrath Schwartz recently pointed out, health care is just 12 percent of our economy. One would like to think that’s because we have a super-efficient health care system the rest of the country should emulate. But that’s not it. Rather, we have a shortage of medical care here. And, because of our health care’s perceived mediocrity, many patients go elsewhere, such as Southern California, to receive care.

That’s why the governor’s own economic development plan notes that an improved health care system is a fast and no-brainer strategy for economic diversification and tens of thousands of good jobs. The federal government is offering $1.8 billion to help us do it.

Expanding Medicaid is the humane and prudent policy choice, so I’m sure we won’t do it.

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  1. "Medicaid expansion should be a no-brainer for Nevada"

    Great! Now the no-brainers in Carson City will have their chance to screw it up.

  2. This same study showed that an 18-25% reduction in mortality would be achieved by private insurance. Let's see 6.1 with medicaid or 18% with private insurance. MMMM Looks like a no brainer.

    Get government mandates out of medical insurance and cut the cost of insurance and make it affordable to all who want it. Much cheaper and better outcomes.

  3. "This same study showed that an 18-25% reduction in mortality would be achieved by private insurance."

    The New England Journal of Medicine study shows no such thing. Why does the right blatantly lie.

    And the lies continue: "The expanded scope promises full support only thru 2020. After that support will drop to it normal 56%. That leave Nevada to pay for middle class people earning up to $88k"

    The Affordable Care Act states 90% of Medicaid costs will be subsidized after 2020.

    The Medicaid expansion covers those with incomes up to 133% of poverty levels. The poverty level for an individual in 2012 is $11,170 see

    The incredibly shrinking Republican Party can thank the pathological liars within their party.

  4. We cannot afford this let alone all the ongoing programs that are draining us dry. There are just too many people in dire straits. If we could expel the hundreds of thousands of illegals, we might have a chance to retain SOME social welfare programs for the blind, aged, disabled. Enough is enough. It is time for people to do for themselves. I'm sympathetic to those who have worked and supported the system for years and years but not for the part-time low-income folks who have skids they won't fully support by relying on "supplemental" income from the rest of us: tax credits for more kids, child care credits and grants, tuition loans, medicaid, chips, food stamps.... Many of these programs are OK for the year or two that you may find yourself on extended unemployment but NOT OK as a way of life.

  5. According to Mitt Romney from his last trip to Israel, the US spends 18% of GDP on medicine while Israel spends 8%. Medical coverage is guaranteed in Israel regardless of preexisting conditions and their medicine is less than 1/2 the expense of ours.

    Mitt congratulated Israel on their socialist medicine, noting the highest quality and efficiency from a government regulated medical industry. Canada also has a fantastic socialized medical program that doesn't evict people from their homes to pay medical bills.

    Medicine is not a place for stock holders or CEOs sporting zoos in their back yards. It's time for reality, not rewards for the privileged.

  6. The thing that mystifies me is that even if this is a no brainer.

    Even if the mortality rate for the State of Nevada would go up with people living longer and healthier.

    Even if twenty-three percent of the people of the State of Nevada has little or no health care coverage.

    Even if it's the right thing to do.

    We just can't do it.

    The reason why is we have a Tea/Republican Party Governor who is more interested in auditioning to be Romney's VP pick more than taking care of the people here.

    In Governor Sandoval's world, the little people don't matter. Because his first and foremost job is to work for the lobbyist/law firm Jones Vargas. This Governor thing is a side line gig.

    Governor Sandoval drags his feet on this because he fully intends for things to stay like they are. His inability to act and do even the right thing is solely due to the Tea/Republican Party mentality. A mentality that is soon to die off and go the way of the dodo bird.

    But in the meantime, Governor Sandoval is the commandant for the death camp called the State of Nevada. Because money is more important than people.

    The problem is that we can do nothing about it. Because he don't listen. Even when it makes sense.

    This issue, in and of itself, will be brought up the next election. And it will be smacked right square in Governor Sandoval's face. He simply don't care about the health, security and welfare of the people of Nevada. Only himself and his dumb political party.

    Bye bye, Governor Sandoval. You have in effect signalled you are unwilling to do the right thing. This signals the people out here are disgusted with your job performance. You're a goner next election. Go operate a death camp somewhere else.

  7. Quote from Romney in Israel:

    "Do you realize what healthcare spending is as a percentage of the GDP in Israel? Eight percent. You spend 8 percent of GDP. on healthcare. You're a pretty healthy nation. We spend 18 percent of our GDP on healthcare, 10 percentage points more."

    He believes their health care system is tops.

  8. If I am reading this correctly it will cost the state about $60 million to run this expanded program.

    UMC loses about $60 Million. Seems like a wash to me and more people are covered for the same money without UMC taking the loss.

    We are shifting dollars with more folks receiving covered health care. I don't see the problem here.

  9. vegaslee: expanded Medicaid won't pay for the ILLEGALS robbing services at UMC over and over again. Their little anchor babies would be covered, but not the illegal parents and illegal siblings. So UMC still loses $60 million.

  10. "When it comes to expansion of Medicaid...the benefits far outweigh the costs."
    I agree.
    Furthermore, I believe that the same could be said of the Affordable Care Act.
    But, as we've all seen many times, a thing being commonsense (or a "no-brainer") does not necessarily allow it to prevail over ignorance or prejudice.

  11. Isn't it odd that Mitt Romney setup a health care system in Massachusetts that is socialized medicine. Isn't it also odd that Mitt Romney praises Israel for their socialized health care. What I find interesting most of all, Israel in general practices socialism, starting with kibbutz communal living to mandatory military service to a socialized educational system. News to Mitt romney, the belief that Israelis are conservatives is false, they are in fact socialists.

  12. So today the "administration" announced they will favor CONVICTED illegal immigrants over the victims of their crimes. This goes beyond pandering for votes. Define TREASON.

  13. The point in expanding Medicaid and/or providing affordable coverage without excluding pre-existing conditions is to indemnify the state from the excessive costs of using emergency room care as primary care, having people neglect preventive care, lack of care for vulnerable children and others, with the net result of filling hospitals needlessly with indigents for whom they will not be compensated, and clogging up the already over extended health care system with people who have allowed routine health care problems to become expensive, urgent care problems. This drives up the cost of medical coverage for everyone. There are no savings when this happens.