Medicaid: The Safety Net We Have Rob Stone MD Director, Hoosiers for a Commonsense Health Plan Assistant Clinical Professor of Medicine, IUSM Director, Palliative Care, IU Health Bloomington

US Census Dept, “ Income, Poverty, and Health Insurance Coverage” Sept 2012 Himmelstein et al, American Journal of Medicine, August 2009 Health Insecurity Indiana 800,000 to 900,000 Hoosiers uninsured Hoosier bankruptcy filings because of medical bills: > 27,000 annually

Affordable Care Act Original projection: million newly covered Half thru Health Insurance Exchanges (Mandate) Half thru Medicaid expansion Supreme Court Decision Summer 2012

Two Very Different Public Programs Medicare Pre-paid health insurance Who Age >65, dialysis, disability How 100% federally funded, the same in every state Medicaid The only safety net Who Low-income people with additional eligibility criteria How 60% federal, 40% state funded

Medicaid 101 Established in 1965 with Medicare Administered by states within broad federal parameters What 73% Caucasian, 19% African American, 5% Hispanic Largest numbers covered – children Largest expense – care of frail elderly, esp in nursing homes Who

Indiana Medicaid % ($95,400) 300% ($71,550) 200% ($47,700) 100% ($23,850) FPL 0 ChildrenPregnantParentsChildless Adults 19% 200% 250% Y-axis is % of Federal Poverty Level; Example of a family of four Premium No Premium

ACA Plan for Premium Support Sliding scale premium subsidies: 100% - 400% of poverty level Medicaid in all states: up to 138% of poverty % poverty: patient’s choice Y-axis is % of Federal Poverty Level; Example of a family of four 400% ($95,400) 300% ($71,550) 200% ($47,700) 100% ($23,850) 0

Medicaid Expansion Would Help People You See Everyday Urban Institute, August 2012, Uninsured Adults newly eligible for Medicaid under the ACA with Incomes below 138% of poverty White 72.7% Hispanic 4.5% African American 18.8% Other 4.0% Parents 45% Adults without dependent children 48% Other 7%

Medicaid Expansion Would Help People We All Rely On

Medicaid Expansion – Good for All of Us Cost to Indiana taxpayers: $ million Federal subsidy: $1.7 billion a year

A Deal Too Good to Refuse HIP cigarette taxes - $121 million High risk pool - $48 million Savings from prisons and jails

“I’m just here for the dental.”

A Deal Too Good to Refuse HIP cigarette taxes - $121 million High risk pool - $48 million Savings from prisons and jails Hospitals avoid $345 M/year unpaid care 30,000 new jobs >$100 million new tax revenues Indiana Hospital Association Report 2/11/13

Medicaid Expansion Is Almost Entirely Federally Funded State responsibility for cost of expansion population

Indiana Is Being Taxed For a Program We’re Turning Down Federal responsibility for cost of expansion population Our federal tax dollars are paying for Medicaid but IN is not getting the benefits

Losing $5 Million a Day

Michigan Chamber Applauds Passage of Medicaid Reform Legislation “Make no mistake, the Michigan Chamber remains strongly opposed to Obamacare,” said Jim Holcomb, Senior Vice President for the Michigan Chamber. “However, our Board of Directors believes Medicaid reform makes sense for our state and the business community.” June 13, 2013

Governor Pence has called Medicaid a “broken program” Is Medicaid worse than no insurance at all?

“Medicaid Patients Have More Complications After Spine Surgery” Hacquebord, J. Spine. Vol 38, Issue 16, P July 15, Analysis Sicker people have more adverse events Sicker patients are more likely to be signed up for Medicaid

“Oregon Proved That Medicaid Does Not Improve Health” Baicker, K. The Oregon Experiment. NEJM 2013;368: Randomized Controlled Trial Expanded Medicaid via a lottery in 2008 Most recent data is two years after the lottery 6,387 newly insured, 5,842 controls Commonly reported results No significant difference in average blood pressure, cholesterol, or glucose Utilization increased, outcomes did not

The Rest of the Story in the Oregon Study Average patient in the study for 17 months Most people don’t have these conditions, diluting any broad population measures Averages for both total populations were normal Study not powered to show broad population impact Intermediate markers showed dramatic improvements Measured endpoints were all encouraging Baicker, K. The Oregon Experiment. NEJM 2013;368:

Oregon: Expand Medicaid, Increase Preventive Medicine All results valid at P<0.02 or better. Baicker, K. The Oregon Experiment. NEJM 2013;368: % more 32% more 103% more

Oregon: Expand Medicaid, Improve Health * Clinically meaningful but not powered to show statistical significance Baicker, K. The Oregon Experiment. NEJM 2013;368: % relative drop* 17% relative drop* 18% relative drop*

Oregon: Expand Medicaid, Improve Mental Health *p<0.05 Baicker, K. The Oregon Experiment. NEJM 2013;368: % less likely to be depressed* 79% more likely to be identified* 33% more likely to be treated

Oregon: Expand Medicaid, Reduce Medical Bankruptcies *p<0.05 Baicker, K. The Oregon Experiment. NEJM 2013;368:

Oregon: Expand Medicaid, Increase ER Usage by 40% Taubman, S. Science Magazine. Jan 2, Annual emergency room visits per person A 40% relative increase means one extra visit per person every four years

Medicaid Expansion Is About Life and Death In Indiana Annual data for Indiana from Dickman S, Himmelstein D, McCormick D, and Woolhandler S. Opting out of Medicaid Expansion: The Health and Financial Impacts. Health Affairs Blog. January 30, 2014 Better women’s health 5,893 more mammograms 14,246 more Pap smears Better treatment of chronic diseases 14,225 more diabetics receiving medications 23,971 less adults with depression Many fewer preventable deaths Between 240 and 758 less deaths Consistent with the “Culture of Life”

Countries with Universal Healthcare