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Medicaid, explained: why it's worse to be sick in some states than others - YouTube
Channel: Vox
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"I was about 11 years old."
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The United States has the most complex
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health care system in the world.
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It's our country's immune system,
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and, like any immune system, it's not perfect.
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"My immune system doesn't know that
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my small intestine is a thing it should not attack."
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That's Matthew.
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He lives in Massachusetts,
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and he has Crohn's disease.
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"Stabbing abdominal pain at like two o'clock in the morning.
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I had imaging done, CT scan,
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incredibly expensive IV antibiotic therapy.
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The worst experience of my life.
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I cannot imagine the stress that going through
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that experience and not having health insurance
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would have caused."
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Matthew is one of the 70 million Americans
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â one in five â
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who gets his health care paid for by Medicaid.
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"Without Medicaid,
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without access to really good medical care,
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I wouldn't be alive.
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Medicaid paid for all of those things."
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But the thing about Matthew is,
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if he lived in a different state, he might not have Medicaid.
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This state-by-state inequality is baked into the Medicaid system,
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and the American health system at large.
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We hear all the time that
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But that's an average.
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There are many states that have great outcomes.
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States where life expectancy, infant mortality,
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and preventable hospital admissions
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look like European countries.
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But not every state.
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If you look at the states below the US average,
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those with the lowest life expectancies,
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the highest infant mortality rates,
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and the most preventable hospital admissions,
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they all have something in common.
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A sizable portion of their population
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doesn't have health insurance.
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Regardless of what you see on TV,
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the most lifesaving medical care in this country
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isn't sexy.
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It's the regular medical care you get
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when you have good, affordable insurance
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that saves more lives.
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Most countries around the world improved
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their citizens' collective immune system
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with a universal health program.
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But America has always been a bit different.
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"The right to adequate medical care, and the
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opportunity to achieve and enjoy good health."
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FDR's New Deal to help the US beat
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the Great Depression in the early 1930s
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focused way more on unemployment and Social Security
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than on health care.
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And there was a reason for that.
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The American Medical Association, the largest trade group for doctors,
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lobbied hard against any form of national health insurance
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whenever FDR proposed it.
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So he and his administration let it go.
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And when they did, private insurance companies stepped in.
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"Private insurance really grew rapidly through the Second World War,
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because there were federal wage freezes,
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and there was a labor shortage."
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"...to fight this war, ten million more people
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must go to work by the end of 1943..."
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"So you're an employer, and you're having a hard time hiring people
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and you're not allowed to offer more money,
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so what you do is you sweeten the benefit package.
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But in other countries, like Great Britain,
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private, employer-based insurance didn't really develop.
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And before it could, the government began offering health care
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to its citizens through the National Health Service, or NHS.
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âThis new health service will be organized
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on a national scale, and so everyone will pay for it,
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and everyone will benefit from it.
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When you're ill, you won't have to pay for treatment."
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But not every European country created a single payer system like Britainâs.
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As in the US, private insurance companies
cropped up
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in Germany and France, but unlike the US,
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those countries regulated these companies closely.
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They had to operate as nonprofits, they had
to cover everyone,
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and they couldnât refuse to pay for something.
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American doctors and insurance companies
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didn't want to see this type of system
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limiting their profits.
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"The percentage of Americans who had
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private health coverage just ballooned
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from about 1938 to 1950.
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And that's when doctors started to get rich.
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The physician community which was very very tight,
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it had very good organization,
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just put their foot down and said 'No.'
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'Never, never, never.'
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President Harry Truman took up the cause
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again in 1948.
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âI have repeatedly asked the Congress to pass a health program."
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But the American Medical Association spent millions
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on PR and lobbying, and Trumanâs plan went nowhere.
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In 1961, President Kennedy proposed Medicare,
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a plan to cover hospital bills for Americans 65 and older
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and the AMA hired Ronald Reagan,
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back when he was an actor, to record this ad.
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âthe doctor begins to lose freedoms,
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and from here it's a short step to all the rest of socialism..."
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Then, in, 1964 President Lyndon Johnson
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won the Presidency by a huge margin.
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âThis administration, today, here and now,
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declares unconditional war on poverty in America.â
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As part of this War on Poverty, Johnson pushed
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Kennedyâs Medicare program through Congress.
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And tucked into that bill was a small provision
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hardly anybody noticed.
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It called for the federal government to give
aid to states
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to help cover medical costs for the poor.
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And that was the beginning of what we know today
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as Medicaid.
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Itâs gone through a number of changes throughout
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the years, but at itâs most basic level,
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Medicaid is a health insurance plan for lower-income
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and disabled adults, and children.
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"Many of them are children, almost half in some states,
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more, and some of them are adults who cannot
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afford private health insurance for a variety of reasons.
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Unlike the Medicare system, which covers all Americans 65 and older,
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states can decide who gets coverage and what gets covered
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in their version of Medicaid.
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There are a few groups of people the federal government
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says states have to cover:
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children and pregnant women in families
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below a certain income,
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plus some seniors and people with disabilities.
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But for anybody else, states get to decide who qualifies.
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In California, a single person who makes $10,000 a year
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qualifies for Medi-Cal, the stateâs Medicaid program.
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When they go to the doctor, they show their
Medi-Cal card,
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and pay a $4 co-pay.
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If they need a prescription, they pay $4.
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The doctor sends the bill to Medi-Cal.
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The State of California pays half,
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and the Federal government pays the other half.
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That split varies by state.
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The federal government would pay a higher
share
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for the same doctorâs visit in Alabama.
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Because federal payments are calculated
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based on the stateâs per-capita income
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But that same person making $10,000 a year,
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wonât qualify for the Texas version of Medicaid.
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In fact, if youâre a non-disabled adult with no children,
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itâs impossible to qualify for Medicaid in Texas.
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States also get to decide what services get covered
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by their version of Medicaid.
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"Whether you get dental coverage, vision coverage,
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podiatry, physical therapy.
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Even hospice, end-of-life care.
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You may not be able to get a hearing aid,
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you may not be able to get glasses.
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There are a lot of services that are
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highly dependent on what state you live in."
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One of the goals of the Affordable Care Act
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was to limit some of this state-to-state variability
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by making Medicaid available to everyone below
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a certain income threshold, no matter where they lived.
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But the Supreme Court struck down that part of the law.
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"The court is leaving open to the states to come back
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and opt in to the Medicaid expansion
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at their discretion."
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"31 states and the District of Columbia made
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Medicaid available to anyone in their state
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who made less than about $17,000 a year.
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In exchange, the federal government reimbursed those
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states for the added cost of covering more people.
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Some governors in states that didnât expand Medicaid
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said they were worried about long-term costs.
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"We canât afford it.
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The state of Alabama will have to pay
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700 million dollars through our general fund
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that we really cannot afford."
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"This is not free money. Every dollar we don't spend
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on Medicaid is another dollar
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we don't have to borrow from China."
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Although the federal government was paying
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100 percent of the cost of expanding Medicaid at first,
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by 2020 that share will drop to 90 percent.
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The Medicaid expansion was paid for by a tax increase,
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one that only affected the top five percent of income earners.
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But it is true that Medicaid costs are rising.
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They made up 10 percent of federal and state budgets 30 years ago,
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and today that share is more than 25 percent.
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Part of that increase is a reflection
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of the rising cost of health care as a whole.
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Health care spending went from about 9 percent of GDP in 1980
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to 17 percent in 2013.
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Although it's worth pointing out that increase
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was much smaller in other countries.
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Conservatives worry that more people on Medicaid
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will only increase costs further.
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"Everyone who qualifies based on a given state's
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rules and eligibility criteria is able to get that service,
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or able to get that benefit, and there's no cap, there's no limit
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to how much the federal government will reimburse states."
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In 1995 under President Clinton and then again in 2017,
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Republicans in Congress proposed changes that
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they said would make Medicaid more financially solvent.
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They would do it by giving Medicaid
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a fixed amount of cash, called block grants,
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not a guarantee of coverage."
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"Block granting basically says, 'here's a big
lump sum,
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and that lump sum you can do with what you want.'"
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And thatâs what Matthew,
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the Medicaid patient from Massachusetts,
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worries about.
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"My particular course of Crohn's disease is
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severe and resistant to treatment."
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That means the medicine he needs to stay alive
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is really expensive.
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"Tens of thousands of dollars per year."
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Before he was on Medicaid, he would fight
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with private insurers who denied coverage.
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"Cigna claimed to lose certified pieces of mail
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and not get faxes in order to stall approval.
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I continued to lose weight.
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I continued to be dehydrated.
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I continued to be malnourished.
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I continued to be in an incredible amount of pain.
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And losing Medicaid wouldn't mean
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he couldn't go to the emergency room.
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It would just mean that when he does,
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he wouldn't get the same kind of treatment he gets now,
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and he'd be stuck with thousands of dollars
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in hospital bills.
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"Everything that's happened to me,
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the dozens of emergency room visits,
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the surgeries, the months worth of cumulative time
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spent as an inpatient in a hospital, all of it,
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could happen to anyone."
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And if it does, and you live in the United States,
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which state you live in can mean the difference
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between life and death.
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"We don't condition public education
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on being a model student.
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If your kid flunks Algebra 1,
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they aren't kicked out of school.
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They get to take Algebra 1 again.
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If someone's sick, they're not morally bad.
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They're not morally wrong.
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They just need health care.
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