What is the counterfactual?
That is the critical question in evaluating any policy. What are the policy outcomes being compared against? Is the counterfactual current law/current guidance of the law? Is the counterfactual current local policy? Is the counterfactual something else? These are all valid counterfactuals for a variety of questions. Choosing one counterfactual over another sometimes will not matter. Sometimes it matters a great deal.
It matters a great deal when analyzing the implications of Medicaid Partial Expansion. The relevant counterfactual will be different depending on the state. Massachusetts should have a counterfactual of current law of full expansion while Georgia should have a counterfactual of current law and local policy of no expansion. Utah is a special case and I’m not sure what the right counterfactual is.
Why does this matter?
Healthcare Dive is highlighting a report from the Kaiser Family Foundation:
Partial Medicaid expansion with Affordable Care Act matching funds could limit state spending, but it will come at the cost of fewer people insured than full Medicaid expansion, according to the Kaiser Family Foundation.
Yes, partial Medicaid expansion will cover fewer people than full Medicaid expansion. If that is not the case, someone is doing partial wrong. But is that the relevant counterfactual in states like Georgia or Tennessee?
I don’t think it is the right counterfactual.
Right now, it does not look like full expansion of Medicaid to adults earning no more than 138% federal poverty level(FPL) is on the table. The choice set is either a change in current policy in the form of a partial expansion of Medicaid to adults earning up to 100% FPL or no change in policy. No change in policy means people earning over 100% FPL and less than 138% FPL still qualify for exchange subsidies and out of pocket assistance. No change in policy means there is significant friction on enrollment that keeps people in this cohort from being continually covered. No change in policy means that almost everyone who earns under 100% FPL will not be exchange assistance eligible and many will not be able to be eligible for Medicaid. That, I think, is the relevant counterfactual for current non-expansion states.
Now for states that have already fully expanded Medicaid but would like to off load some costs back to the Federal government in the form of a partial expansion of Medicaid, current policy and current law is the relevant counterfactual.
Determining the right counterfactual determines the questions which determines the answers one gets. Getting the counterfactual right is critical.
On the Road and In Your Backyard
Uncle Cosmo
O/t but – may I make a friendly suggestion? Have you considered emulating Cheryl by starting your own healthcare policy blog & crossposting here? IMO you’d stand a much better chance of getting some meaningful discussion going. Here most of your threads are met with stunned silence because only a very very few jackals are (again in my estimation) ready & willing & able to accompany you on deep dives through the major & minor arcana of the subject. (E.g., I hold a master’s in applied statistics, so in theory I should be able to follow the material, but TBH my eyes usually glaze over by the third para.)
rikyrah
Can you talk about how it’s legal with states trying to limit Medicaid after the voters VOTED to expand Medicaid.
Barbara
I had a long comment that got eaten, so I am shortening it. The answer from a health policy perspective is easy, but you are wrong to see this as primarily an issue of health policy. We have a way of expressing the collective will, and that is through the enactment of statutes by Congress. These states have always been (a) net federal tax recipients and (b) incredibly stingy with providing Medicaid coverage. They turned down free money because they didn’t like the policy bargain that was enacted. They should not be allowed to, essentially, rewrite the statute to reflect their own policy preferences when those are contrary to what Congress enacted. This isn’t just a rule of law thing. This is fundamental to the idea that individual states cannot decide to participate only in those collective actions that suit their own policy preferences.
Michael Cain
@rikyrah: I assume you’re talking about Utah. Ballot initiatives in the West come in all sorts of flavors. In California and Colorado, where it’s almost as easy to amend the state constitution as to pass statute, many changes are embedded in the constitution where legislators can’t touch it (Colorado’s constitution is embarrassing larded up with such). In Arizona, the constitution says the legislature can’t touch initiative statutes for five years. In Utah, statutes enacted by initiative are no different than any other statute and are fair game for the legislature. (Same thing in Montana, where the voters approved medical marijuana some years back, the legislature whittled away at it, and in 2016 the voters approved another initiative tossing the legislature’s changes.)
Matt
“These states are going to try to hurt their citizens no matter what, so we should evaluate policy changes positively if they make the hurt less.”
Nope. We should continue to state loudly and clearly to citizens of GA and TN: “YOUR STATE GOVERNMENT IS FUCKING YOU OVER ON PURPOSE FOR NO GOOD REASON”.
Barbara
@Matt: I would just encourage everyone to understand how most of these states are already favored under the current Medicaid funding mechanisms, called FMAP, which has never had the effect of making them more generous. States are generous or not depending on whether they value Medicaid beneficiaries as citizens and voters, not whether they need the money for other things. Source
Michael Cain
@Barbara: Here’s the FY2020 FMAP numbers. Wyoming is the outlier, the only state getting the minimum match that has not expanded its Medicaid program. Wyoming is peculiar in lots of ways.
Barbara
@Michael Cain: It’s getting harder to compare states because the non-expansion states are now basically their own universe, but prior to expansion, the states that have not expanded yet typically had among the lowest percentage FPL coverage under the original Medicaid program. So these states are not just turning down 100% sharing, but the proportion of Medicaid eligible participants in these states is almost certainly higher as a total percentage of all Medicaid eligible adults. These are the states that would benefit the most from the expansion, in terms of additional federal dollars flowing to the state. In 2013, the states with the lowest percentage FPL thresholds for Medicaid coverage were Arkansas, Alabama, Indiana, Louisiana, Texas, Mississippi, Virginia, Kansas, West Virginia and Missouri.