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July 09, 2012 12:52 PM One Step Back, Two Steps Back

By Aaron Carroll

So now that the Medicaid expansion is optional, some states are trying to see if they can make other parts of Medicaid optional, too:

Within hours of the Supreme Court’s ruling on June 28, lawyers in the Maine attorney general’s office began preparing a legal argument to allow health officials to strike more than 20,000 Medicaid recipients from the state’s rolls—including 19- and 20-year-olds—beginning in October to save $10 million by next July.
“We think we’re on solid legal ground,” Attorney General William Schneider said in an interview. “We’re going to reduce eligibility back to the base levels in a couple of areas,” he said. Maine, like some other states eyeing cuts, earlier expanded its Medicaid program beyond national requirements.
Other states, including Wisconsin and Alabama, are expected to follow Maine’s lead, though there is disagreement over whether the high court gave the states such leeway. That could lead to battles between states and the federal government that could drag the health law back to the courts. New Jersey and Indiana also said they were evaluating the decision and did not rule out challenging the requirements.

This is where we are? Trying to find ways to make more people uninsured? Even the math is crazy. If I’m reading that first sentence right, Maine is looking to drop people from insurance that’s costing them about $500 per person. Really?

When the ACA was passed, it cemented in place whatever eligibility existed in individual states. Since they knew the expansion was coming, the feds didn’t want states to go bare bones in order to put even more expansion cost on the federal tab later. A number of states tried to cut their rolls, but were denied:

Wisconsin recently sought to remove 60,000 people, including children, from its Medicaid rolls, but federal officials denied the move. The two sides ultimately reached a deal to strip 17,000 Medicaid beneficiaries.
“I think the logic of the Roberts decision would reopen the matter,” said Mr. Smith, who was the top federal Medicaid official during the George W. Bush administration.
Don Williamson, Alabama state health officer, said officials are looking at restricting eligibility for Alabama’s children’s health insurance program for the fiscal year starting Oct. 1 if federal officials officially lift the ban on changing eligibility. The move is aimed at closing a $15 million funding gap for the program, he said.

The numbers we are talking here are so stunningly small when it comes to health care in general that it’s hard to imagine why this would be where we’d focus.

I try to stay dispassionate on the blog. This is one of those times it’s hard. I’ve already received numerous people sending me this story in a gloating manner, as if it’s some “victory”. It’s not. For anyone.

Medicaid isn’t “welfare”. It isn’t cash money. You can’t take your Medicaid and go buy cake. Or cigarettes. You can’t rest easy once you’ve got Medicaid. It doesn’t get you a roof over your head, or food on your table. It doesn’t even act as a disincentive to earn.

It provides you with health care – if you need it. If you’re healthy, it doesn’t do anything. At all.

And without it, you really can’t get that health care. Remember, we’re talking about people at the lowest end of the socioeconomic spectrum. If you’re single and work 30 hours a week for a whole year at the federal minimum wage, you make more than the poverty line. So if you don’t have Medicaid, you’re not getting health care. No asthma meds. No diabetes checkups. No mammograms or colonoscopies. No mental health treatment. No help with your insomnia, your rash, your heartburn, or your arthritis. Because even if you could go to the emergency room for these things, it wouldn’t be free.

The cost to the US for health care is a real concern, yes, and trying to get it down is important. But the reason we’ve focused on it so much the last few years is because many people felt that the access problem had been improved dramatically. If we’re really going to start trying to go backwards on that front before we’ve even gone forwards, then I have no idea what’s going on at all.

[Cross-posted at The Incidental Economist]

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Aaron Carroll ,MD, is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine.