Eduardo Porter’s New York Times column last Wednesday, “The Costs of Stinginess In Medicaid,” is a provocative reminder there are human costs that come with decisions not to expand Medicaid, as called for by the Affordable Care Act. Porter’s piece is timely, as the drive to get health care to more people covered under Medicaid is under “assault,” as Politico put it last week, since the Republicans’ sweep in November. That some four million of America’s poorest people are disenfranchised from the health care system is a big story that requires ongoing coverage in the states that have not expanded or are considering private options as a compromise. Porter’s column provides an interesting way to look at objections to expansion, which almost always involve money, and advances the story in an often-neglected direction.
Porter highlights a new study by Yale researchers that, he writes, “underscores just how costly scrimping on Medicaid can be.” The researchers used national data and compared children born in 1981 in Vermont and Arkansas. They estimated that Vermont’s more generous eligibility standards would have cost the state and federal governments almost $5,000 more per child than in Arkansas, measured in 2011 dollars. They also found that easier access to Medicaid translated into more payroll taxes when the children grew up. By the time they reach age 60, Vermont’s children will have repaid 56 cents of every Medicaid dollar spent on them when they were kids. Porter also makes the point that healthier and well-nourished children are likely to be more productive adults requiring less government assistance, and adds that children with behavioral problems who receive counseling early in life are less likely to end up in prison, a big cost to the states. In other words, early investment pays big financial dividends for states in the long run, not to mention improvement in these children’s lives now and later on.
This argument takes a long view of poverty and the role of good health in lifting people out of it, something that researchers who specialize in the social determinants of health like food, housing, and income have emphasized for a long time. In a long read in The Guardian earlier this month, the well-known Harvard philosophy and economics professor Amartya Sen argued in a persuasive essay:
Reduction of economic poverty occurs partly as a result of the greater productivity of a healthy and educated population, leading to higher wages and larger rewards from more effective work but also because UHC [universal healthcare] makes it less likely that vulnerable, uninsured people would be made destitute by medical expenses far beyond their means.
So far, though, this view has not penetrated the rhetoric flying around in the 28 states that have either not expanded Medicaid or that have devised a private option that allows the state to pay private insurers to provide the benefits and requires Medicaid recipients to contribute copays or other cost sharing. Some states considering those options may try to make it hard for recipients to get benefits. Indiana, for one, wants to charge premiums for residents with incomes below the poverty line and kick people off the program if they don’t pay. Arkansas, the subject of the Yale research, tried a private approach last year but, according to Politico, voters defeated many of is supporters. It seems rational discussion of why expansion might be good for the state in the long run is mixed in with–and sometimes overwhelmed by–dislike for the law itself. “There are people who strongly believe they were sent here to kill Obamacare,” Jodiane Tritt, a vice president for the Arkansas Hospital Association, told Politico.
It may be a tough slog to get the public and their representatives to listen to arguments about investing in poor people’s health right now to reap financial benefits for the state years down the road. Still, those covering Medicaid expansion need to try to broaden the discourse beyond the all-too-typical story quoting opponents versus supporters that rarely clues us in to what’s at stake. If reporters are going to take the dollar sign approach to reporting this topic, Porter’s column and Sen’s powerful essay show that their perspective needs to stretch beyond this year’s state budget.
Related content:
What’s missing from Medicaid coverage…actual people
How to report on Medicaid in 2015
Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.