Oregon launched a lottery in 2008 that had nothing to do with gambling.
Instead of money, the winners got health insurance.
The state allowed working-age adults living in poverty to apply for its Medicaid program. Thousands received coverage.
A study of those newly insured Oregonians found that they felt healthier and happier and more financially secure. They also spent 25 percent more on health care than those who did not win insurance.
The Oregon experiment may foreshadow one of the biggest potential public health impacts of the 2010 Affordable Care Act (ACA), also known as the health reform law or Obamacare.
The law, which recently survived a challenge in the Supreme Court but still faces strong Republican repeal efforts, is chiefly about extending health care coverage to as many Americans as possible, partly through an expansion of Medicaid.
One part of the court’s ruling set up an unexpected but enormous decision for Georgia and other states: Whether to expand their Medicaid rolls to uninsured adults living in poverty. In Georgia, more than 600,000 would gain Medicaid eligibility under such an expansion.
But even if Georgia rejects the Medicaid expansion – and many in the state don’t want anything to do with the ACA – the reform law still contains many provisions that can boost the state’s public health, experts say.
Southern governors voice opposition
The Supreme Court, by invalidating an ACA enforcement provision, made Medicaid expansion optional for states. Soon after the ruling, some governors, notably those in Florida, Louisiana and South Carolina, indicated they were dead set against pursuing expansion.
Under the law, the federal government will pay 100 percent of the expansion in the first three years, and 90 percent afterward. But governors said the costs would still be too high for their states.
“We already have a Medicaid program that covers the most vulnerable people in our state,” Florida Gov. Rick Scott, a Republican, said last week. “I don’t know if we have another $500 million, $700 million. I don’t know where it’s going to come from.’’
Georgia Gov. Nathan Deal has taken a wait-and-see approach on Medicaid expansion.
Georgia has about 2 million uninsured residents, or roughly 20 percent of the state’s population. The more who get coverage, either through Medicaid or the health insurance exchanges that the ACA will create, the better for public health in the state, health experts say.
Many of the uninsured have chronic health conditions that could be better managed with regular access to health care, notes Dr. Harry Heiman of Morehouse School of Medicine in Atlanta.
Those without coverage, he says, are 6 to 7 times less likely to see a doctor when they’re sick, which often makes their illnesses more difficult and expensive to treat later on.
Georgia’s public health system is currently struggling on several fronts, partly due to years of budget cuts. The state has high rates of obesity, infant mortality and cardiovascular deaths, and diabetes and asthma remain major problems as well. State officials have launched initiatives to reduce these rates, but there’s a long road ahead.
The ACA has provisions besides insurance coverage that can help the fight against chronic diseases, which are responsible for 75 percent of health care costs in the nation.
Ken Thorpe, an Emory University health policy expert, points out that the health reform law makes more than $10 billion available to fund evidence-based prevention and care coordination initiatives. It includes efforts to reduce smoking and obesity, he notes.
Through what’s called Community Transformation Grants, more than $4 million has already been awarded to Georgia help communities reduce chronic disease rates, address health disparities and strengthen prevention efforts.
Another provision of the law is the national diabetes prevention program housed in the CDC, Thorpe says. This initiative has, in randomized trials, reduced the incidence of diabetes among pre-diabetic overweight adults by 58 percent, he says. Community-based delivery of the program — largely by YMCAs — has been shown to reduce health care spending.
And through the state insurance exchanges, beginning in 2014, health plans must offer enhanced clinical preventive services and benefits with no cost sharing, such as mammograms, colonoscopies and other cancer screenings.
There’s also money for behavioral health screening, HIV/AIDS prevention, and for the training of public health workers. The health law has provisions for reasonable break times for nursing mothers in the workplace, and programs to improve oral health.
“For public health, there’s a lot of good in the ACA,’’ says Phaedra Corso, department head of health promotion and behavior at the University of Georgia’s College of Public Health.
The law has awarded millions to community health centers to expand access to care, and boosts primary care by paying those physicians more, Corso notes. Employers can also earn incentives by creating wellness programs.
“If you have a wellness program,’’ Corso says, “people will manage diabetes better.’’
But she acknowledges that states with financial difficulties face a hard choice on Medicaid expansion if they’re also forced to take money away from areas such as education. The feds may have to figure out a way to get these low-income people into the exchanges, Corso says.
If Medicaid or insurance coverage are not expanded, the burden on local public health departments is likely to get bigger.
That’s because safety-net hospitals are losing federal dollars to treat the uninsured under the ACA. Without a corresponding increase in patients who have coverage, those hospitals may struggle to treat their current numbers of uninsured. And those patients, as a last resort, may end up seeking services at county public health departments.