- If Mississippi wants to improve health outcomes, and not just engage in very expensive window dressing, it must do two things: reduce the instances of obesity and increase the supply of medical providers.
For much of the last two decades, the healthcare debate in America has misguidedly focused on the question of how we pay for an expensive and broken system, instead of focusing on how we fix the system. Because of this flawed framework, we regularly and mistakenly conflate access to an insurance card with good health.
The Medicaid expansion debate in Mississippi is a prime example. In assessing any proposed healthcare reform, the measure of success should be if the policy improves health outcomes. Everything else is just a means to an end. There is ample evidence that Medicaid, by itself, does not.
For instance, even without Medicaid expansion, Mississippi has the eighth largest percentage of its residents on Medicaid in America. Nearly one-third of the state is on the program. If Medicaid participation was a good marker of healthy outcomes, the state might expect to rank positively among its peers. But Mississippi ranks 49th in health outcomes nationally according to America’s Health Rankings and last in life expectancy.
Louisiana and Arkansas to our west have both expanded Medicaid. Louisiana in 2016. Arkansas in 2014. Despite massive increases in Medicaid enrollment and expense, both states continue to struggle when it comes to health outcomes. Louisiana ranks 48th in the nation. Arkansas dead last.
Early in the public relations push for Medicaid expansion, advocates attempted to lean on high instances of maternal mortality in Mississippi as a reason to expand. The argument was disingenuous since Medicaid expansion would not increase eligibility for pregnant women. A pregnant woman in Mississippi can already make up to 194 percent of the federal poverty level and maintain eligibility for Medicaid. It is a much more generous eligibility standard than Medicaid expansion’s cutoff at 138 percent. But even with this increased access, the Mississippi Department of Health’s own maternal mortality report showed over 70 percent of the pregnancy-related deaths in Mississippi were on Medicaid at the time of death.
To be clear, I am not saying that Medicaid causes poor health outcomes. Just that having a Medicaid card in your wallet does not naturally translate to positive outcomes.
Over the last few years, I’ve told anyone who would listen that if we are really concerned about health outcomes in our state, we should be laser focused on two issues: (1) reducing instances of obesity (I do not say this in judgment for I am a self-acknowledged offender); and (2) increasing the supply of medical providers.
Mississippi has the fourth highest instance of obesity and the second highest instance of diabetes, an obesity-related chronic illness. Other leading causes of death, such as heart disease, hypertension and certain forms of cancer, are also closely tied to obesity. Obesity is the most significant driver of demand on Mississippi’s healthcare system.
These are regional problems with which our neighbors to the west also struggle. Louisiana, as an example, has an even higher rate of obesity than Mississippi despite expanding Medicaid. The state with the highest rate of obesity and diabetes-related deaths, West Virginia, expanded Medicaid in 2014.
To compound the problem of lifestyle choices creating extra demand on the healthcare system, Mississippi has the worst physician shortage in the nation, a problem projected to get much worse as approximately one-third of our existing physicians near retirement age.
Giving people an insurance card does not translate to increased access to care if there are no medical providers available to see patients. Studies done by researchers at both Harvard and Stanford have found that Medicaid expansion does not meaningfully increase the number of medical providers willing to treat Medicaid patients. This results in more people competing for the same number of treatment slots.
Ironically, some of the same people who most loudly advocated for Medicaid expansion this year have been the most fervent opponents of any reform that would have increased the supply of medical providers over the last decade. Whether telemedicine, giving advanced practice nurses more ability to treat patients, reforming the certification process to allow more providers in our communities (sometimes called “CON” laws), or allowing pharmacists more ability to test and prescribe basic medications, many in the medical establishment have fought tooth and nail any idea that would expand the provider pool and create competition.
The simple fact is that without reducing instances of obesity and increasing the supply of providers, any policy the Legislature enacts, including Medicaid expansion, is spitting in the wind.
Finally, a word on the arguments made by Medicaid expansion supporters this session. Two predominant arguments surfaced in the debate over Medicaid expansion.
First, proponents argued that the goal of expansion was to give health insurance to the working poor. Not only does having an insurance card not guarantee positive outcomes, but this was and continues to be a false talking point, one based in a 2014 reality and not the reality we currently find ourselves in. In 2024, people earning between 100-138 percent of the federal poverty level already have access to $0 premium, $0 deductible, and $0 co-pay private health insurance through the ACA exchange. The federal government subsidizes almost all of the expense and the insurance companies eat the rest.
The Center for Medicare and Medicaid Services (CMS) says there are 181,844 Mississippians in this income bracket enrolled in one of these “free to the end user” plans. Under the Mississippi House’s original expansion plan, these individuals would have been moved off of their private insurance onto Medicaid.
In other words, the overwhelming majority of the “working poor” in Mississippi already have health insurance and would have been kicked off of it by Medicaid expansion. That’s counter-productive.
Kaiser Family Foundation estimates the actual number of adults working who have access to neither Medicaid nor the ACA exchange to be roughly 33,000. The Senate’s original partial expansion plan, up to 99 percent of the federal poverty level and with a work requirement, would have ensured coverage for this small subset.
Second, supporters have harped on the false talking point that Mississippi is passing on “free” federal money.
I’ll explain by analogy why this tired talking point does not hold water. The state is not passing up federal dollars by not committing to full Medicaid expansion.
Imagine you went to buy a car with a wealthy benefactor who offered to help pay for it. You look at two models that the benefactor says he is willing to finance. One of the cars is more expensive and your benefactor says he will pay for 100 percent of it. The other is less expensive and your benefactor says he will pay for 90 percent of the cost. When you select the more expensive car, has the dealership lost out on any money it would have gained if you’d chosen the other? Of course not. In fact, it made more.
This is the same setup as with Medicaid expansion. The federal government is the benefactor. The state, the dealership. The Medicaid recipient, the person getting a “free to them” car.
Right now, the federal government is paying 100 percent of the cost for a more expensive insurance option (the ACA exchange). If the state were to fully expand, it would lose this payment. Instead, the federal government would start to pay only 90 percent of a less expensive option (Medicaid), or in the case of a “hybrid” model, 90 percent of the ACA exchange cost. Either way, the state is not losing the money proponents claim.
Russ Latino
