published Thursday, July 3rd, 2014

Cleaveland: State inertia could kill the poor people

By Dr. Clif Cleaveland

We will never know how many Tennesseans have needlessly died because they lacked access to health care. Hundreds? Thousands?

These residents may have had cancers that could have been cured by early diagnosis. They may have had coronary disease in which earlier diagnosis and treatment would have prevented fatal heart attacks. Warning signs of stroke could have been heeded. Chronic infections could have been addressed.

TennCare, our state's version of Medicaid, provides health coverage to persons who earn up to 100 percent of the Federal Poverty Level. Provisions of the Affordable Care Act of 2010 expanded Medicaid coverage for each state to include persons and families earning up to 138 percent of FPL (slightly less than $16,000 per year). As an incentive for expansion, the ACA would pay all costs related to Medicaid expansion for three years. Thereafter, 90 percent of costs for those added to the Medicaid rolls would be covered indefinitely; Tennessee would receive $1.6 billion for expansion.

The U.S. Supreme Court struck down the requirement for Medicaid expansion on June 28, 2012, the 7-2 majority concluding for various reasons that individual states could not be compelled to expand health insurance programs for poor people. The constitutionality of the ACA, including the individual mandate, was upheld by a 5-4 majority.

Twenty-six states and the District of Columbia have chosen to expand their Medicaid programs under terms of the ACA. Arkansas and Kentucky are among those choosing this route. Rates of Medicaid expansion in these states average 15 percent since implementation. An estimated 6 million additional low-income people have Medicaid coverage as a consequence.

In those states not expanding Medicaid programs -- which include Tennessee, Georgia and Alabama -- enrollment increased by 3.5 percent. An additional 8 million low-income people would become eligible for Medicaid if all states expanded their programs under ACA guidelines.

In cities situated on state boundaries, this has presented striking contrasts in access to health care. A New York Times article of June 8 illustrated the differences in cost and access to health care of disadvantaged residents of Texarkana, which straddles the Texas-Arkansas state line. Poor residents on the Texas side of the city, where Medicaid eligibility ends at 25 percent of FPL, had strikingly higher costs for medical care -- and residents usually only sought it in emergencies -- than their neighbors on the Arkansas side of the city. Surprisingly, few of the low-income residents of the Texas side of town moved to the Arkansas side. Inertia and a distrust of government programs were cited as reasons.

Other split communities include Memphis, Chicago-Gary, Ind., and the Maryland and Northern Virginia suburbs of Washington, D.C.

Despite the reluctance of state leaders to expand Medicaid programs in Tennessee, Georgia and Alabama, enrollment has increased as documented in Times Free Press reporter Kate Harrison's thoughtful report in the May 28 edition of this paper. Growth in TennCare enrollment has occurred despite increased red-tape and delay in the enrollment process. Increased enrollment in Tennessee has placed unexpected stress on the state's budget.

A questionnaire for the governors, legislators, and candidates for these offices in Tennessee, Georgia and Alabama:

• Is health care a right or a privilege? If it is a right, who guarantees that right?

• Does state government have a responsibility to protect vulnerable populations such as poor, sick, and/or homeless persons?

• If you oppose the Medicaid expansion provision of the ACA, what do you propose as an alternative that can be rapidly and efficiently enacted?

• Have you personally interviewed poor families who have no health insurance?

• Will you publicize your answers?

Until these states devise a mechanism to expand access to health care to low-income residents, I propose the erection of a tomb on state capitol grounds to commemorate anonymous poor persons who die because of political inaction or political indifference.

Contact Clif Cleaveland at cleaveland1000@comcast.net.

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