Uninsured Numbers a Compelling Case Against States' Rights

“States’ rights” is as popular a rallying cry as ever as we enter the early stages of the 2012 election campaign. 

To advocates of states’ rights, they are code words for state innovation and initiative, unhampered by the demands of a federal government.   In their minds, we are a United States of America. 

To skeptics, we are a United States of America, and states’ rights are the code words of political leaders who want to run their states as fiefdoms and answer to no higher authority. 

The new 2010 uninsured numbers released by the U.S. Census Bureau last week make a compelling case against the states’ rights position.

In the South, where the drum roll for states’ rights beats most loudly, 19% of all people were uninsured 2010 for the entire year.  This was more than in the West, where 18% were uninsured, the Midwest, where 13% were uninsured, and the Northeast, where only 12% were uninsured.

Place clearly matters where health insurance is concerned, and innovation and initiative in providing coverage for health care take a back seat in the Mecca of states’ rights.

Geography is an important factor in determining insurance status, but it isn’t the only one.  Others include:

·         Race and ethnicity – 31% of Hispanics were uninsured for the entire year, as were 21% of blacks;

·         Immigrant status – 34% of all foreign-born U.S. residents were uninsured, including 45% of those who are not citizens and 20% of those who are;

·         Income – 27% of people in households with less than $25,000 per year were uninsured.

But as bad as these numbers look, what’s behind them in the more detailed tables that accompanied the Census Bureau release is worth examining. 

It isn’t race, immigrant status, or income driving the health insurance numbers.  It’s geography.

Consider this fact.  The news headlines reported that 16.3% of the population of the United States as a whole was uninsured.  But when you remove people over the age of 65 – who are almost universally insured through the federal Medicare program – the percentage rises to 18.4%.

But in the two biggest southern states of Florida and Texas – where the new leaders of the states’ rights movement sit in Governor’s chairs – the numbers are far worse. 

In Florida, 24.6% of all people under the age of 65 were uninsured in 2010 for the entire year.

In Texas, 26.9% of all people under the age of 65 were uninsured in 2010 for the entire year.

Florida has earned its states’ rights badge through Governor Rick Scott’s attack on the Affordable Care Act.  His administration has refused to implement its consumer protections.  He has famously refused to accept public funding for many needed services because the funds were associated with the Act.  And he has turned down dollars to set up a health insurance exchange that would make more privately-funded insurance available in the state, too. 

Texas has earned its badge through Governor Rick Perry’s attack on Medicaid.  He has advocated repealing the Medicaid program in its entirety, making Medicaid a block grant so that Texas can do whatever it wants with it.  He once suggested seceding from the union if he didn’t get his way.

The one thing that neither Rick Perry nor Rick Scott can do is blame the federal government for the failures of their states to insure their populations properly.  Nor can they blame racial, ethnic, immigration, and income factors.

Mississippi, South Carolina, Maryland, and Georgia all have higher percentages of African Americans than Texas and Florida, but lower percentages of uninsured people.  New Mexico has a higher percentage of Hispanics than Texas, but a lower uninsured percentage.  And California has more undocumented immigrants than Texas and Florida combined, but a lower uninsured percentage, too.

Florida and Texas are also by no means the poorest states in the union. 

Florida and Texas have reached the bottom of the uninsured barrel through their own policy actions and despite their considerable assets.

When their governors talk about states’ rights in the area of healthcare, they seem to be arguing that every state should aspire to their level of failure.

Meanwhile, the one thing everyone seems to agree on is that more people in Texas and Florida will become insured when the Affordable Care Act is implemented by the federal government in a little over two years.

This has been characterized in recent Presidential debates as a federal takeover of health insurance.  But does anyone seriously believe that we would ever have needed an Affordable Care Act – or that it would have passed – if every state, including Texas and Florida, had taken care of its own problem like Massachusetts did?  

In Massachusetts, only 6% of the population was uninsured in 2010.

If you have questions about this column, or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Entitlement Reform Could Lead to Mental Health and Health Care Armageddon

It was hard to witness the embarrassing spectacle of politicians responding to the credit downgrade by circling their firing squad yet again.

I’d like to see some grown-ups emerge from the mess.  But I’m not holding my breath.

Sources: CBO, GIH, KFF, CDC, NAPH

Our debt problem was caused by tax cuts that didn’t create jobs, wars for which we didn’t pay, and an unsustainable and under-regulated financial bubble that burst.  It wasn’t caused by entitlements.

Despite this, politicians are pushing entitlement myths and reforms.  But in the unsteady hands of this unstable Congress, entitlement reform could result in a health and mental health care Armageddon that could blow us all back into the 19^th century – the stone age of modern medicine.

The Social Security and Medicare Trust Funds still have surpluses.  They aren’t responsible for the debt.  In fact, Social Security Trust Funds hold U.S. debt, just like China.

We can do two things about future Social Security and Medicare costs.  We can cut benefits, which our citizens don’t want, or raise Social Security and Medicare taxes to pay for the benefits people do want.  It would take a 1%-2% Medicare tax increase to preserve Medicare as it is today for the next three generations.

Medicaid is a different story.  Medicaid doesn’t have a trust fund.  It contributes to the federal deficit and debt, and we need to lower its cost. 

However, the federal deficit this year will be at least $1.3 trillion.  The entire federal share of the Medicaid program is approximately $300 billion. 

Suppose Congress passed the most radical entitlement reform possible – eliminating the entire Medicaid program – as Texas Governor Rick Perry once proposed.  The federal deficit would still be over $1 trillion.

The debt wouldn’t go down much, either.  Our national debt is over $14 trillion today.  Before the passage of the recent deficit reduction act, the CBO projected that the debt would grow to $23 trillion by 2020.  The Act reduced this by almost $1 trillion in Round 1, with at least another trillion to come in Round 2. 

If Medicaid’s $300 billion per year, plus inflation, were made part of Round 2 cuts by the “SuperCongressional Committee,” the U.S. debt would still be almost $20 trillion in 2020.

This assumes that there would be no bad outcomes from such a radical action.  However, eliminating Medicaid would kill health and mental health care in America. 

If Medicaid were eliminated, then the number of uninsured people would mushroom to one-third of our population.  Many would have chronic diseases.

We would witness the first major fallout within a few weeks.  Sixty percent of nursing home beds are funded by Medicaid.  So nearly every nursing home in America would collapse, unable to finance their operations.  Frail elders and people with chronic conditions would be released.  Social services providers would be overwhelmed.

Within a few months, the fallout would spread to every community health center in America.  Without Medicaid, which accounts for 37% of CHC revenue, they, too, would crumble.  Millions of their patients would flood into hospitals for care. 

Most hospitals could probably survive this onslaught for a year or two, but the pressure on them would be terminal.  Public hospitals, which get 35% of their revenue from Medicaid, would fail first. Then private hospitals, which get 17% or more of their revenue from Medicaid, would fail, leaving vast areas of our national landscape without emergency, trauma, or surgical care. 

Behavioral health services, which get 26% of their revenue from Medicaid, would implode next.  People with mental illness would be out on the streets or hidden away without services.

Private physicians could hold out a little longer.  But within a few years, patient-hoarding would be their only survival strategy, and most of their practices would die.  A few urgent care centers, surgical centers, and concierge practices would remain, but their prices would skyrocket.  Few could afford them.

By 2020, without Medicaid pretty much all that would be left of our health system would be our public health services and our $20 trillion debt.  A significant percentage of 14 million healthcare jobs would be lost.  Life expectancy would plummet to pre-1900 levels, and most diseases would be death sentences again.

“Entitlement reform” is a new catch phrase for politicians who do not want to face reality.  To balance our federal budget and pay off our accumulated debt, we will have to raise taxes, pay for the wars we’ve already fought, and create more jobs – including jobs in the public sector, in which one in every six U.S. workers is employed.

The discourse in our Congress must be more grown-up.  We must pay for what we have already consumed and what we want in the future.

But paying bills is a bigger nightmare to some politicians than destroying our health and mental health care systems.  So the demonizing myth of entitlements will continue.

If you have questions about this column or wish to receive an email notifying you when future Our Health Policy Matters columns are published, please contact gionfriddopaul@gmail.com.

Column note:  There are more hyperlinks than usual in today's column, and I want to thank especially the Congressional Budget Office, SAMHSA, the Center for Medicare and Medicaid Services, the Center for Budget and Policy Priorities, Grantmakers in Health, the National Association of Public Hospitals, Gallup, the Federal Bureau of Labor Statistics, the Kaiser Family Foundation, and the Centers for Disease Control and Prevention for the valuable information they make available through their web sites for use by people like me!