That is all I am able to answer when asked what the ACA nuances mean for Pennsylvania. And the only answers that the state administration has provided. A hard deadline comes soon, forcing a decision on setting up a state-lead insurance exchange. But a much more tenuous quandary has seemingly no time frame- will the state accept the largely federally bank-rolled Medicaid expansion, or leave potentially hundreds of thousands of people off the health care rolls?
Sentiment in the state seems mixed at best, with editorials summing up the results of working with the federal government on the ACA as, “ Once fully realized, ObamaCare will have all the appeal of a perpetual flu.”  While the governor's official position is still undecided as it waits for further communication with HHS, Governor Corbett at a recent press conference said "I don’t think there’s any way we can absorb this,” on the costs to the state of expansion. The governor’s office anticipates the expansion state would cost the around $350 million in its first year and a total of 2-4 billion over 5 years, citing further concerns that the Medicaid budget (and other social services) already encompasses between 35-40% of the state budget.
But let’s be quite clear what this money, from a relatively wealthy state, would be covering. The current Medicaid eligibility levels are set at 46% of the federal poverty level for single adults. To be blunt: that is $5,138 a year. The full federal expansion would cover everyone up to 133% of the federal poverty level, nearly tripling the eligibility level to $14404 for a single person.
That’s an additional 550-750,000 people who will have access to medical care in the state. An additional half to three-quarters of a million people who will not be forced to forego necessary preventative care leading to much worse health outcomes in the long run.
That additional 4 billion dollars in state spending(which does not take into account all the cost-improving initiatives going on at all levels of medical care) can sound overwhelming. But if we look at absolute costs, it can seem almost trivial in comparison to what the state would gain. Over the next 10 years Pennsylvania is expected to spend $133.4 billion dollars without expanding coverage to 750,000 citizens. The cost with the expansion? $136.3 billion. That is a state-level difference of 2.1%, over the course of 10 years. The federal government foots the bill for 100% of the initial expansion, and it declines by only 10% over the course of the next decade.
There is no question that as healthcare providers, patients, and a political unit we must continue to find innovative ways to lower costs while continuing to provide quality care. But one way this is not done is by increasing the barriers to access for needed medical care. By getting almost a million people plugged into a system that can help encourage both prevention and treatment before circumstances become dire, it can help bring down long term costs. We must be careful to remember that if the state is not helping to fund this access, someone in the long term will. Medical needs are not something that go away. They only fester, and grow with time. This is also important for the hospitals that provide uncompensated care for those who might be denied access if these programs are not embraced. As the ACA anticipated the number of patients being treated in this category, the funds meant to help replenish those coffers are going down. In addition to patients, care facilities stand to gain a great deal from this expansion.
But now let’s step back, and ask a larger question: in this game of numbers, what is it that we are really buying?
We are buying a sense of security for citizens of this state, and this country. We are creating a baseline for the more vulnerable members of our country, a footing for them to start striving for more. Data has now shown access to Medicaid in particular improves mortality outcomes, and at rates comparable if not better than private coverage. It also removes the burden for people to forego seeking medical treatment, as increasing cost sharing and lacking coverage often does. People do not choose to forego care of questionable value, or that more expensive luxury treatment. Data instead also indicates it is the lower income brackets who forego the most, and they go without recommended services. We cannot guarantee outcomes for any of our citizens, but we can come closer to guaranteeing them a fair chance.
Likewise, we can also provide reassurance to people living in the middle classes, a comfortable life which is subject to the same trepidations of a health catastrophe as everyone else. We can give the entrepreneur a promise of a soft landing, as some well-meant endeavors invariably fail. That is part of the beauty of this country- we should feel secure enough to take risks, knowing that if those risks fail, we have a chance for reinvention. Choosing to invest money on the front end for programs such as the Medicaid expansion allow us to align our budgets with our values.
And for the sake of those who stand to benefit around the state and the country, I hope Pennsylvania soon stops waiting, and chooses to embrace this generous program which costs the state little compared to both the financial and social good it can do.