Gov. John Bel Edwards’ budget-busting expansion of Medicaid could cost taxpayers more than previously thought, if not deprive people with serious disabilities of the help they need.
Even though during his term, Medicaid expansion will “save” the state no money; even though afterward, it will cost the state by 2029 a projected almost $600 million extra a year; even though, once accepted, Louisiana legally cannot exit the program; and even though research demonstrates that Medicaid patients’ health outcomes end up no better — if not worse — than the similarly uninsured, Edwards committed to it.
With the state’s Medicaid expenditures, up to 80 percent in eight years, expected to top one-third of the upcoming year’s budget, this unwise move will have disastrous fiscal consequences and not improve the poor’s health. Even so, Edwards is bowing to demands of leftist ideologues and part of his electoral coalition at unnecessary cost to the citizenry.
A constitutional amendment passed in 2014, for which Edwards voted as a legislator, exacerbates the looming crisis. That change essentially locked in the Medicaid reimbursement rate for privately operated nursing homes, adjustable upwards by inflation, despite Louisiana’s institutions having among the lowest occupancy rates of the states.
Worse, the formula pushed up the rate artificially by including non-Medicaid patients, and it also pays operators more than $15 million annually for empty beds due to overcapacity. Reductions only could occur with two-thirds legislative majorities or in conjunction with cutting other providers — an option the federal government is unlikely to approve.
Other providers left most at risk include the major alternative to nursing homes: home- and community-based services, which have borne rate cuts, even as nursing home rates have increased dramatically in recent years. Those reductions translated into fewer hours granted for those clients with coverage and fewer potential Medicaid-eligible clients covered outside of institutions.
Potentially compounding these service delivery problems, a federal court recently ruled that Washington had to provide ventilator-dependent children on Medicaid with home coverage, which that state had failed to do as a result of low provider reimbursement rates. That state now must appropriate extra money to boost payments.
This decision signals the federal judiciary’s willingness to determine whether states make a good-faith effort to provide indigent care through Medicaid in the least restrictive setting as required by federal law. Louisiana looks particularly vulnerable on this standard, with waiting lists to receive home- and community-based care nearing 50,000 names and the state projecting spending this year of $80 per capita on these services, compared with $209 for nursing homes. By contrast, the South Central region states’ projected averages are $146 for waiver services and $138 for nursing homes.
Because of state dedications that favor nursing home operators, if the federal courts stepped in as they did at the turn of the millennium with the Olmstead decision in Louisiana and declared that the state had to provide more home- and community-based coverage, only huge tax increases could meet this mandate. Even without this kind of judicial directive, expansion’s costs would necessitate tax increases or forcing people with disabilities into institutions and/or denying them care.
Health and Hospitals Secretary-designate Rebekah Gee, wrongly calling expansion “access to quality health care,” alleged that Edwards’ governorship would “have compassion.” But it is far from compassionate to take more of what people earn to increase subsidies for inefficient health care that lacks quality compared with other alternatives, likely at the expense of the seriously disabled.
Jeff Sadow is an associate professor of political science at Louisiana State University Shreveport, where he teaches Louisiana government. He is author of a blog about Louisiana politics at www.between-lines.com, where links to information in this column may be found. When the Louisiana Legislature is in session, he writes about legislation in it at www.laleglog.com. Follow him on Twitter, @jsadowadvocate. Write to him at firstname.lastname@example.org. His views do not necessarily express those of his employer.