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Both sides present arguments in Medicaid debate Upstate Chamber Coalition hosts forum By april a. morris | staff
As employers and insurers brace for the full implementation of the Affordable Care Act in 2014, states have been debating one part of the legislation: whether to participate in Medicaid program expansion. The federal government has offered to pay for the first three years of expansion, ramping down the federal share in subsequent years to 90 percent. States have to come up with a 10 percent match to receive the federal funds. Gov. Nikki Haley has said that South Carolina will not take the deal, citing the uncertainty of future funding from the federal government. According to the Advisory Board Company, 24 governors supported expansion as of early March. In a forum sponsored by the Upstate Chamber Coalition, Tony Keck, head of the state’s Department of Health and Human Services, and Thornton Kirby, president of
the South Carolina Hospital Association, outlined the arguments for and against Medicaid expansion in South Carolina. Kirby said the question has put those who normally partner on opposing sides. For states, he said, the biggest difficulty has been willingness to put up the initial investment – a little more than $1 billion – by 2014 to receive more than $10 billion in federal money. Uncertainty about sustaining federal funding is a close second. States “have a fear that the federal government will not keep its commitment financially,” he said. Whether a state opts to expand Medicaid or not tends to track political leanings nationwide, he said, with primarily Democratic states opting in and primarily Republican states opting out. “The nation is divided on this question. This is a partisan political issue, it’s got a lot of ideology embedded in it.” Hospitals are required to treat the uninsured and the ACA aims to cover those uninsured and reduce cost, Kirby said. Hospitals are also anticipating cuts in federal funding, but don’t know when these will take effect. “What hospitals see through their lens is a lot of cuts coming and the possibility
of bringing a lot of federal money to the state to backfill. And the question is, ‘Is this a wise course of action?’” he said. Someone must pay for indigent care in every state and the Medicaid expansion will help, Kirby said. “Through Medicaid, the other 49 states are offering to help us bear the lion’s share of that cost,” he said. “If we don’t opt to let them help us pay for that, we must pay for it within our borders.” Expanding Medicaid wouldn’t be worth it for the state, Keck said. In South Carolina, the expansion would bring roughly 344,000 new people into the Medicaid system, he said. Already, some states that have expanded Medicaid early have had to declare a Medicaid deficit, he said. “When it comes down to it, when we talk about whether to expand or not expand, it will affect the lives of about 200,000 people in South Carolina out of about four and a half million,” Keck said. Meanwhile, “the other 4.3 million people are in a (healthcare) system that is not working, they’re in a system that’s out of control.” Keck said the solution is not to expand Medicaid, but to improve health by increasing value in the healthcare system, including
moving away from a fee-for-service model, focusing on total cost, outcomes, pricing transparency, pushing for clinical integration and examining why costs are so high. “We probably wouldn’t be all worked up about this spending if we had the best outcomes in the world,” he said. Improving social determinants like education, personal choices and economic status will make a huge difference. Much of a person’s overall health does not have to do with the care they receive, but with other factors, he said. “Our system is so fragmented, you’ve got hospitals, all sorts of doctors, home health, nursing … all of them try to maximize their returns and outcomes independently,” Keck said. “Integration makes better sense. We can’t continue to chop people up into little bits and try to solve their problems – we’ve got to view them as a whole person.” Healthcare is one of the nation’s largest industries and needs to be treated as such, he said. “Purchasers (like us) and employers need to look at this like one gigantic negotiation.” Contact April A. Morris at amorris@communityjournals.com.
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MARCH 8, 2013 | The Journal 19