With the election over, Nebraska faces some important decisions that could affect health care for tens of thousands of the state’s residents.
Addressing a Platte Institute meeting last week, Steve Martin, CEO of Blue Cross and Blue Shield of Nebraska, gave the audience this assessment of the Affordable Care Act, or ‘Obamacare.’
Steve Martin, Blue Cross and Blue Shield
“It’s not possible to repeal it, unless someone has the magic formula here, it’s just not possible. We don’t have the votes in the Senate, and we have a president who would veto it. So at least for four more years it’s not going to be repealed,” Martin said.
That means Nebraska is going to have to make some significant decisions, including whether or not to expand Medicaid. Currently, that government insurance program is mainly for the aged, blind, disabled, children in low income families and their parents. But the health care law will allow – not require, after the U.S. Supreme Court’s ruling in June – states to cover adults without dependent children at annual incomes up to 133 percent of the federal poverty line. That’s about $15,000 for a single person, or $20,000 for a two-person household.
Linda Manns of Bellevue said that would be big help for people like her. “That would be great ‘cause it would be a great relief on hospital expenses,” Manns said. “I just got out of hospital like 2-3 weeks ago. And I had no coverage. So now I have to worry – my husband and myself have to worry -- about how are we going to pay for that?”
Manns said she has worked all her life and always had health insurance. But then she lost her job as a certified nurse assistant, because her diabetes kept her from working the overtime her employer required. Her husband makes about $10,000 a year as a dishwasher.
So Manns said she hesitated before going to a doctor for an infected toe that had to be amputated recently. “I was almost going to let it go, ‘cause I had had a prior infection in one of my toes, so I assumed it was the same thing on this toe. And I was going to say, ‘Well, it got better last time. I really can’t afford going anywhere.’ So I was going to put it off.”
But then, she said, things changed. “It got real bad, just overnight. And my blood sugars were running high,” Manns said. “If I would have waited, they told me I could have lost my leg.”
Avoiding that kind of result is one of the main goals of expanding health care coverage, according to Juliann Sebastian, dean of the University of Nebraska Medical Center’s College of Nursing.
Juliann Sebastian, UNMC
“If we make the assumption that more consumers will have access to health insurance of some kind – and we don’t know how many, but if we make that assumption that this will increase – people will have the ability to seek care much earlier in the trajectory of potential illness,” Sebastian said. She said other changes in the health care system, including an increased emphasis on wellness and prevention, will help as well.
Getting patients treated earlier could help save money compared to the costs of treating those same patients under the existing system, said Dr. Ward Chambers, a UNMC cardiologist. “By federal law, we can turn no one away from our emergency room – nobody can. And that’s where the folks that are not insured are getting their health care,” Chambers said. “They’re waiting until it is too late, in many cases, and seeking the most expensive health care we have available.”
But the issue of cost has generated the most outspoken and potentially powerful opposition to the idea of the state expanding insurance coverage for poor people.
“We can’t afford the Medicaid expansion,” said Gov. Dave Heineman. He said the existing Medicaid program is already consuming a lot of state tax dollars. And he argued expanding it would take away from other things Nebraska should be doing.
“If Medicaid expands, let me tell you who’s going to get hurt: state aid to the Lincoln public schools, the Bellevue public schools, the Kearney public schools; funding to UNO, UNK, the Med Center and the University of Nebraska’s going down. Or you’re going to raise taxes on middle class families. And I’m opposed to every one of those (outcomes),” he said.
The governor cited a study done for his administration two years ago by consultant Milliman, Inc. It said the state’s share of additional Medicaid costs could add up to $766 million by the year 2020.
A UNMC study this year put the state’s cost much lower, at $168 million. And it suggested that cost needs to be weighed against benefits, including up to $3.5 billion in new federal spending in the state, which could produce more than 10,000 new jobs.
Both of those scenarios depend on the federal government living up to its commitment in the new law to pay all the costs of Medicaid expansion for the first three years, eventually phasing down to 90 percent by 2020.
But Ed Haislmaier of the Heritage Foundation questioned that assumption. “Basically you cannot trust that the federal government will continue with those match rates; indeed, the president’s budget proposal for this year proposes a 'blended' match rate that would save the federal government money,” Haislmaier said.
In other words, Haislmeier suggested, over time the federal share for expanded Medicaid could drop from 90 percent towards the 57 percent the federal government pays for the existing Medicaid program.
Despite these concerns, Blue Cross and Blue Shield’s Steve Martin said deciding on expanding Medicaid is a balancing act. “I think the Legislature has to debate that,” Martin said. “I share some of the governor’s concerns. I also share the concerns of those who don’t have access to health care.” Martin said uninsured people “still drive our costs up because they’re going to get it (health care) and you’re going to pay for it anyway in the private premium.” He was referring to the fact costs incurred treating people who can’t pay their bills wind up being shifted onto others, including those with insurance.
Despite all the uncertainty, UNMC’s Ward Chambers said changes related to -- and separate from -- health care reform offer good possibilities. “”While there’s a lot of gnashing of teeth…I personally view this as an opportunity, as a provider, to build a system that provides higher quality health care at a lower cost for our patients,” he said.
But even if it’s easier for people to get coverage, UNMC director of health planning Fred Salzinger said not everyone will make that choice. “I just don’t know if the people will take that level of responsibility. And we’ll still have an indigent care load and they show up, not when they have a runny nose, but when they have a major episode and we’ll have to care for them,” he said.
One thing that seems certain is the Legislature and the governor will spend plenty of time considering all this in the coming months.
Editor's Note: An earlier version of this story contained incorrect information about the health insurance exchanges for people with incomes too high for Medicaid. That information has now been omitted.