A half-million more Michiganders will be eligible for Medicaid, the government-funded health program for poor people, when the most sweeping provisions of the Patient Protection and Affordable Care Act take effect in 2014.
Supporters of the law say covering more poor people is not just socially responsible, it ultimately saves money: Better care keeps chronic conditions in check.
But opponents will argue this week to the U.S. Supreme Court that Congress is overstepping its bounds by pushing the expansion onto states, which will lose their federal Medicaid funds if eligibility is not expanded.
Some argue the expansion will be financially catastrophic. The conservative Heritage Foundation, a leading critic of the plan, estimates the change will cost Michigan $835 million through 2020. Others argue that savings in health reform will make up the costs.
Compounding the problem is waste within the current Medicaid system, because some patients may not worry about bills they never have to pay — contributing to costs that will increase as the system grows even larger in 2014, said Dr. Matt McCord, a member of a national group of doctors fighting the new law.
It’s like boarding a flight while someone else picks up the tab, said the Ann Arbor anesthesiologist. First-class or coach? Destination? Who cares? It’s the same price, McCord said.
Benefits, pitfalls seen in Medicaid’s growth
Perched on an examination table in a health clinic on Detroit’s east side last month, John Perry said he didn’t know about the legal intricacies of the Affordable Care Act, or of the arguments in front of the U.S. Supreme Court this week.
Right now, he’s just trying to survive.
Perry, a former cook, most likely would be among the estimated 500,000 Michiganders who, in 2014, would become eligible for Medicaid under the Obama administration’s road map to health care reform.
Perry, 54, never thought he would have health insurance. Like many Americans with no small children, he has been denied Medicaid repeatedly, because it is geared mostly toward disabled people and poor families with children.
So he takes his blood pressure medicine and tries not to eat too much fatty food. He walks to keep healthy — a habit made easy by his inability to afford a car or gas, he said, chuckling.
But Medicaid, he said, will come just in time.
He worries about his aging body, which seems to have a few more aches and pains these days: There’s “no telling what comes down the road,” he said. “Everyone needs doctors some time.”
Since President Lyndon B. Johnson signed it into law in 1965, Medicaid has been jointly funded by federal and state budgets.
On average, every dollar in Medicaid benefits spent in Michigan on more than 1.9 million beneficiaries consists of about 66 cents from the federal budget and 34 cents from Michigan’s budget.
Those match rates vary by state, and states don’t have to participate in Medicaid. But all states do, collectively drawing billions of federal dollars each year to provide health care to poor residents.
Under health care reform, by 2020, federal funds will pick up 90 cents of every dollar for new enrollees after 2014. But there’s a new condition on participation: States must expand coverage to include nearly anyone up to 133% of the federal poverty level. In 2012, the federal poverty level for a family of four is $23,050.
Not only will expanding coverage mean picking up more families, it will mean covering folks like Perry. And that comes with a hefty price tag.
Cost of treating people
Last year, Medicaid cost the state $2.1 billion; the federal government kicked in $8.4 billion — a larger-than-usual portion because of stimulus funds, according to the Michigan Department of Human Services.
State health officials said they have not estimated how much the 2014 expansion will cost because there are too many unknowns — exactly how many people will be eligible and what kind of care they will seek, for example.
And there are jaw-dropping differences in estimates elsewhere.
A report funded by the New Jersey-based Robert Wood Johnson Foundation, which advocates for increased health care for all, concludes that savings under health care reform and a larger federal match for the new Medicaid program will more than make up for costs to states.
In contrast, the conservative Heritage Foundation, which opposes the reform law, estimates that Medicaid expansion will cost Michigan $835 million between 2014 and 2020; the figures were extrapolated from federal predictions for overall costs and each state’s match rates, said Ed Haislmaier, a senior research fellow.
Opponents say the program is already fraught with waste and fraud, and that its expansion will bankrupt states. And this week before the U.S. Supreme Court, they will argue that the Medicaid expansion is unconstitutional as well and that Congress has overstepped its bounds.
It is “a huge added new burden of fiscal irresponsibility,” said Michigan Attorney General Bill Schuette, a Republican. Michigan is among 26 states whose attorneys general have filed briefs against the Affordable Care Act.
Opponents argue the Medicaid expansion is coercive. States must pony up some of the Medicaid funds, even if it’s just 10%, but it is lawmakers in Washington who tacked on the new condition to expand eligibility.
At Mercy Primary Care Center, a free clinic on Detroit’s east side, Perry’s care is privately funded, mostly by Trinity Health, a national health system in 10 states, including Michigan. And though it doesn’t currently accept Medicaid or any other federal money, it could once expansion takes place, said its medical director, Dr. Margaret Meyers.
Mercy estimates that 85% of its patients will be covered by Medicaid. Many of its patients are poor people with low-wage jobs, like hair stylists, security officers or certified nursing aides, Meyers said. She said she thinks that regular health care for newly insured patients such as Perry can keep chronic conditions in check and save millions of dollars.
Undiagnosed and unchecked diabetes, for example, can lead to blindness, amputations and death — exorbitant expenses compared to medications and doctors’ visits that could help keep the disease under control, Meyers said.
Life with, without care
Ginger Dillon, 49, is blunt about it: She has a disease that most likely will kill her.
“Medicaid is the reason I won’t die as quickly and with so much pain,” she said.
For years, she’d had mysterious but debilitating pains that knotted her back and shot through her neck, odd rashes, even bouts of unexplained hoarseness. A restaurant cook, she said that at the end of a shift, her feet “felt like every bone in them was broken.”
Laid off in 2008 and with no insurance, Dillon went to emergency rooms when the pain was unbearable.
But emergency doctors were unable to stitch the fragmented symptoms into a single diagnosis. But last year, she was squeezed into a small Medicaid category in Michigan when it opened for new enrollees for a short time. She was lucky; the small fund covers fewer than 50,000 Michiganders.
Finally able to get primary care and access to a specialist, Dillon was diagnosed with relapsing polychondritis, a rare, autoimmune disease in which her body’s cartilage is breaking down.
“Medicaid saved my life. Or at least, it let me stop thinking I was crazy,” she said last week, as she left her appointment at Covenant Community Care, a clinic in Royal Oak.
And that puts Dillon in an awkward position philosophically.
She knows her care — the drugs that keep the disease at bay as much as possible and ease her pain — could result in a bigger cost for others because Medicaid is taxpayer-funded. Plus, she’s appalled at the Affordable Care Act’s mandate that everyone have insurance or face penalties.
But without it, she and others could be cut from care.
“I’m selfish in the way that I don’t think the government should tell you what to buy or not to buy. What if it’s just $10 a month, but you don’t have that $10? I’ve had those times,” she said.
“But I think every human being should have access to a doctor, too. I hate this pain, and I’m not ready to die and to die this way. … Maybe that’s selfish, too.”
Patients with insurance often don’t understand what it’s like to go without, said Meyers of Mercy clinic — to see chronic conditions spin out of control without medication or to endure painful injuries that go untended.
Even Mercy, which offers services ranging from gynecological exams to diabetes eye care and on-site pharmacy, is limited by its budget and the number of doctors willing to offer services at low to no cost.
A man recently made his way in with a broken foot, Meyers recalled. The best Mercy could do: Give him a hard, orthopedic shoe. And the bone? We “had to let it heal on its own,” Meyers said.
Concerns over growth
Dr. Richard Armstrong, a general surgeon in Newberry in the Upper Peninsula, is chief operating officer of the national organization Docs4PatientCare, which opposes the federal health care reform law.
He and others in Docs4PatientCare said millions of dollars each year are spent for things that could be addressed with a bit of common sense, and that waste will only grow under the provisions of the new law.
No one should be denied treatment for life-threatening medical emergencies, Armstrong said. But he worries about patients who appear at a hospital’s emergency room at 1a.m. with a headache.
Treating their headache — processing, lab work, doctor’s fees — can top $600, even though they most likely will leave with a bottle of Advil.
“They know they can do it — go to the ER and get the care for free,” he said. And that, he added, is cheaper than “going to a gas station and buying a bottle of Advil.”
Medicaid waste is just half the problem. On the Medicare side, the health reform law expands coverage of wellness visits and prevention services at a time when baby boomers, who began turning 65 last year, age into the system.
It’s more opportunity for waste because many visits might really be about doctors reminding patients about things they already know, Armstrong said.
“So (a patient named Jack) weighs 300 pounds and the doctor tells Jack to lose weight, and Jack leaves and the doctor gets $75 for telling him” what the patient already knows, Armstrong said. “That kind of visit happens thousands of times a day, and Medicare pays for it.”
Beyond costs and the legal questions, some opponents say an expansion of Medicaid is philosophically misguided, too.
In January, Woodhaven resident Stan Rogers, 70, traveled to Lansing to testify against the Affordable Care Act along with other critics.
It’s not a perfect world and everyone can’t have everything, said the retired military veteran and mortgage broker and grandfather of four.
“There’s nothing in the Constitution that says health care is mandatory or an entitlement,” he said.
More Details: People on both sides take action
The U.S. Supreme Court is tackling the legal intricacies of the Affordable Care Act, but the debate extends beyond the courtroom.
In Michigan, about 40 people with the group Americans for Prosperity-Michigan ( www .michigan afp .com ) will head to Washington on a tour bus at 10:45 p.m. today to protest the health law and meet with congressional representatives. They will return early Wednesday, said director Scott Hagerstrom.
“This really is an issue that moves people,” he said.
And while that bus rolls toward the Capitol, another — this one carrying supporters of the law — will move into Michigan.
The Young Invincibles ( www .young invincibles.org ) is a national group representing Americans 18-34, said Matt Lawrence, the group’s spokesman.
Lawrence, 26, originally from West Bloomfield, said the tour plans to meet with young Americans in 18 states, then carry their stories back to Washington.