County Officials: We’ve Seen What Medicaid Expansion Can Do

WASHINGTON — In his first address to a joint session of Congress, President Trump on Tuesday doubled down on his campaign promise to “repeal and replace Obamacare.”

Despite their inability thus far to come up with a replacement plan they can agree on, Republican lawmakers responded to this portion of the speech with resounding applause and a standing ovation.  

Many county health officials, if they were present in the room, would likely not have been clapping.

Just six hours before Trump’s speech, in a packed Capitol Hill briefing on Medicaid and the role of counties in local health systems—part of the National Association of Counties 2017 Legislative Conference—county officials from across the country made one thing clear: They have seen what the Affordable Care Act and Medicaid expansion can do for health outcomes, and they’re nervous about what might be coming down the pike for these programs they’ve come to rely on.

‘Lives Have Changed Dramatically’

“Medicaid expansion has allowed over 600,000 Michigan residents to be covered” by health insurance, said Robert Sheehan, the chief executive officer of the Michigan Association of Community Mental Health Boards and a member of Tuesday’s panel.

Simply put, “if you’re in an expansion state, you know that lives have changed dramatically,” Sheehan told the room of fellow health officials.  

But, those county officials in states that have expanded Medicaid also know that the increase in coverage hasn’t just meant that counties are able to help change the lives of low-income members of their community, it’s also an issue that affects the bottom line of local budgets.

Across the country, counties are the “safety net provider for those unable to get care,” said Toni Carter, a county commissioner in Ramsey County, Minnesota, during her portion of the briefing presentation. And, in many cases, counties aren’t just providing this service because of feelings of moral obligation. In the majority of states, counties are, in fact, required by law to provide health care for low-income, uninsured or underinsured residents—that’s care that is often not reimbursed.

Programs like the Affordable Care Act and Medicaid are saving these counties an impressive amount of money by off-setting costs of uncompensated care. And in terms of Medicaid in particular, these county officials are anxious to keep the open-ended entitlement program as it is.

At the county level, providing health care to citizens is often an exercise in responding with the unexpected. Even with impressive improvements in surveillance techniques and big data analysis, you can never be completely prepared for every health scenario that might arise.

Turning Medicaid into a block grant program or a capped program, county officials argue, would put harsh limits on local health departments and their ability to act effectively to address unexpected health problems.    

The opioid epidemic is a prime example of a tragic problem that came as a surprise to many local health workers.

“Five years ago, if I had been told ‘you are going to be conducting syringe access exchange programs in your department,’” said Georgia Heise, “I would not have believed it, nor would our health department have believed it.”

Heise is the public health director of the Three Rivers District Health Department, an agency that serves four predominantly rural counties in Kentucky, and speaking of the opioid epidemic in her area she said, “you have to be nimble to address things like that.” The cost of setting up that needle exchange program is likely not one Heise would have been able to foresee.

Sheehan contends that with the insurance coverage and funding provided to counties by the Affordable Care Act and its related Medicaid expansion, states like Michigan, his home, have been able to respond to the opioid scourge as they never would have been able before. In fact, Sheehan says he’s been “stunned by how well the Medicaid expansion is working.”

Counties Want More From Affordable Care Act and Medicaid Reform, Not Less

Conversations about Medicaid often ignore county-level involvement.

“Medicaid is normally described as a federal-state program, most people don’t realize counties play such a critical role in funding the program,” Carter said.

Yet, in fiscal 2012 alone, counties contributed $28 billion to the Medicaid program. So, given that contribution, county leaders want a voice in the conversation about the future of the program.

Georgia Heise, for example, wishes the Affordable Care Act and Medicaid expansion had gone hand-in-hand with increased investment in health education. In her view, these programs provided health coverage to people who had never had coverage before, but those people inherently lacked the tools to make the most of that care.

In addition to providing care to residents who cannot afford health care or do not have insurance, counties are also required by federal law to provide care to the nearly 11.5 million people who spend time in 3,100 local jails every year. Sixty-eight percent of this population suffers from a substance abuse disorder, and 40 percent has a chronic health condition. Sixty-four percent of this population has a mental illness. The majority of those inmates are awaiting trial and have yet to be proven guilty of the crime they are being held for.

And Carter, like many county health officials, would like Congress to do away with the rules that prevent those inmates in jails from receiving Medicaid benefits while they are serving time.

Strained budgets leave many counties unable to give sick inmates the full spectrum of care they need. Problems resulting from that lapse in treatment eventually trickle out to the wider communities in these counties, since more than 95 percent of these inmates will leave jail and reenter society.

County officials like Heise and Carter made it clear on Tuesday that what they want out of reform for the Affordable Care Act and its related Medicaid expansion is to increase the scope of the programs even further, rather than diminish them.