“Not everything that is faced can be changed, but nothing can be changed until it is faced.” (James Baldwin)
With a proven record of cutting waste and reducing spending, I am a fiscally conservative Republican, as well as a health care professional. But the Georgia GOP legislative leadership and I have reached very different conclusions about Medicaid expansion and the Affordable Care Act (ACA).
Nationally, my party has passed legislation in the House more than 50 times to repeal the ACA, also known as Obamacare. The ACA was implemented anyway and shows no sign of going away. So, is the ACA working? And what about Medicaid expansion here?
I was a senior corporate and government planner. Planners evaluate programs in one of two ways, based on: 1) history, or 2) the ideal.
I will address the historical method first.
According to both federal officials and a 2014 Gallup report, there has been a precipitous drop in the number of uninsured people under the ACA. The U.S. Department of Health and Human Services states that the national rate of uninsured is 9 percent for the overall population and 12 percent for those under 65. According to HHS, the ACA has been responsible for covering 20 million more Americans since it was enacted.
Medicaid expansion was a key factor in realizing this drop in most states, although not here. Republicans, like other Georgians, should be concerned that Georgia now has the third-highest rate of uninsured in the nation.
Demographically, the national decrease is uneven. The rate dropped much more for Hispanics (from 42 percent down to 21 percent) and blacks (from 22 percent to 10 percent) than for whites (from 14 percent to 7 percent). It should be no surprise that, according to surveys, the ACA is more popular among Hispanics and African-Americans.
Likewise, according to Gallup, the drop in the rate of uninsured was greatest in those under $36,000 in household income (from 31 down to 25 percent). Among higher-income households, the drop was much less.
In Georgia, 74% of those in the “coverage gap” are minorities.
I do not know exactly what influences the thinking of the Georgia GOP leadership when it comes to expanding coverage. But I am very concerned when key legislators make unsubstantiated — and factually incorrect — statements, such as saying that Medicaid expansion would cover “Georgians who are fully capable of getting a job that would provide them with private health insurance.”
Of Georgians in the coverage gap (low-income people who don’t qualify for either Medicaid or ACA exchange discounts), 57 percent are in working families. Surely our GOP legislative leaders know some low-income working people. Do they seriously believe that these men and women do not want good jobs that provide them with health insurance?
Regarding the second evaluation method, comparing the ACA to the ideal is much more difficult. When researching the developed world for other insurance models, we find that there is no need for something like Medicaid expansion (or weird “waivers”). All of these nations cover everyone under a coordinated, comprehensive system.
There is the direct government delivery model. Britain has had a National Health Service since the end of World War II. Our experience with this format has not been as positive, as shown by the VA scandals.
Another system used in some European nations is to have a small number of highly regulated private insurance carriers, where everyone gets coverage. These nations all have lower costs and better outcomes than here.
Finally, there is the model in which the government provides insurance covering to all citizens. The Canadian system can be likened to a “Medicare for All” program here, where it would cover every citizen. Surveys have shown a high level of satisfaction among Canadians with their system.
But what about cost? Let’s look at a 2013 report from the Organization for Economic Cooperation and Development (OECD), which includes all the developed nations worldwide.
With our fragmented system, we spend 17.7 percent of our GDP on health care. Canada spends only 11.2 percent and covers everyone. Many other nations spend much less. Australia, for instance, spends just 8.9 percent. The average OECD nation spends only 9 percent.
Per capita, we spent $8,508 for health care in 2011. Canada came in at $4,522. The average OECD (developed nation) spent only $3,339 per capita!
Oddly, we spent more tax dollars on health care (VA, Medicare, Champus, Medicaid, etc.) than almost any other developed nation. We just do not spend our money as wisely. Pandora’s box regarding cost escalation was opened here a long time ago by Big Pharma and private insurance companies.
And, according to a 2013 report by the Institute of Medicine, of 17 high-income countries examined, we are at the bottom in many health indicators.
In 1960, life expectancy in the United States was 1.5 years above the OECD average. In 2011, our nation was 1.5 years below the other OECD nations.
So, what can we conclude about the ACA? First, it is much better than what we had before, regarding health care access and coverage.
Secondly, a Canadian-style “Medicare for All” system would cover everyone — and at less cost — clearly a better option than the current ACA and its Medicaid expansion provisions.
I agree with our state GOP leaders that the ACA is imperfect, but it is what we have in the short term to provide coverage to the uninsured. My question to these leaders is: “Why aren’t you advocating for Medicaid expansion instead of for depriving the working poor of insurance coverage?”
Jack Bernard is a former Director of Health Planning for the state of Georgia. He retired as an executive with a national health care corporation.