Health Reform and Medicaid in Montana

May 31, 2013

A recent article in the May 2 issue of the New England Journal of Medicine reports on a study of a group of adults in Oregon who were given the option of applying for Medicaid health insurance in 2008.  This study is important because it shows what happens when uninsured people do get health insurance; in this case Medicaid.  Our own state legislature recently decided in a very close vote not to accept federal funds to expand Medicaid in Montana.  Despite this, or maybe because of it, we all need to understand some of the important facts about health, health care, and health insurance.

The Oregon experiment clearly shows that providing Medicaid health insurance to a group of uninsured poor adults does improve access to health care.  It also improves; self-assessment of healthiness; the diagnosis, treatment, and symptoms of depression; the diagnosis and treatment of diabetes; cholesterol screening; and frequency of pap tests and mammograms.  People were more likely to have a regular doctor and access to what they felt was high quality, comprehensive care.  Also, and as expected, Medicaid insurance leads to significantly lower rates of medical debt and catastrophic spending on medical care.  

Poor people are sicker than rich people whether or not they have insurance.  But having insurance and therefore improved access to health care for just two years, as in this study, doesn’t mean that many aspects of health will be measurably improved for any group of people, rich or poor.  What it does mean is that if you get sick, you can get the kind of care you need, sooner rather than later, and you won’t go broke because of your illness.  You are more likely to get needed preventive care, to feel healthier and less depressed, and to get any chronic illness treated.

But, health is much more than health care.  Our health in the U.S. is significantly and measurably worse than every other developed country in the world.  We live shorter lives and suffer more disability.  This is true even for educated, high income people in the U.S. compared to their peers in other countries. There are multiple reasons for this including our fragmented and specialty oriented medical system and our very high rates of under and un-insured.  But our poor health is also due to many factors that are not directly related to actual health care.  The U.S. has more segregation, violence, drug and alcohol abuse, lung disease, heart disease, AIDS, infant mortality, teenage sex, stress, and poverty.  We exercise less, have a poorer diet, and have more environmental health barriers than other developed countries.  We also have very different attitudes about the role of government in helping to create a healthy society.

Because of the Affordable Care Act, starting this coming October, anybody in Montana earning more than about $11,000 a year will be able to purchase affordable health insurance.  Coverage will start on January 1, of 2014.  This insurance will be available without regard to age or prior illness.  It will be comprehensive.  Different insurance options will be easily comparable.  In Montana it looks like three insurance companies will be competing in this health insurance marketplace, called an exchange.  It will be accessible over the internet.  Insurance brokers and others will be trained to help people but individuals can do it themselves.

Each person or family will be able to choose the insurance plan they want to purchase.  Costs will vary depending on income and which plan is chosen.  For those who are not earning very much, the cost will be subsidized and affordable.  For many people and some small businesses who are now buying their own insurance, it will make financial sense to purchase through the exchange because of these subsidies.

For those who are newly insured we can expect improved access to timely and comprehensive health care along with less financial stress.  This may well be true for people who are currently insured but with expensive and less comprehensive policies.  But we should keep in mind that having insurance will not improve many of the factors that lead to poor health in the U.S.   

Unfortunately, we have missed a rare opportunity to provide Medicaid or any insurance to those who are less well off in our state.  As a result, these needy people will continue with worse health care and worse physical, financial, and mental health.  The advantages of having health insurance, including Medicaid, are very clear.  To think otherwise makes no sense.  We need to understand that what we do collectively regarding all aspects of health determines how well we live.  This failure by our legislature to expand Medicaid has not been a positive step towards good health in Montana.