Kantarjian, Ho: Expanding Medicaid under ACA would avert state health crisis

The Hippocratic Oath has been the guiding moral compass for physicians for 25 centuries. Despite its ancient origin and the astounding progress in medicine, two of its principles have proven universal and timeless: Protection of patients against harm and injustice at an individual and societal level.

But these principles are at odds with the way health care is practiced in the U.S. Almost all developed nations have universal health care, which is considered a human right. The one glaring exception is the United States, where health care is a for-profit industry, and where we still argue whether it is a human right or an entitlement.

American exceptionalism, the for-profit health care industry and physician concerns over personal income are the triad that hindered progress toward universal health care. In 1965, President Lyndon B. Johnson implemented steps toward universal health care by establishing Medicare and Medicaid, which also desegregated hospitals nationwide. Little progress occurred over the next 50 years. Efforts to expand health care were met with resistance.

Today, U.S. health-care spending is more than double most European nations (18 percent versus less than 10 percent of GDP), and is the sixth-largest economy in the world. Despite vast spending, many studies rank U.S. health care near the bottom among developed nations.

The basic premise of the Affordable Care Act (ACA) is to provide better and more expanded health care at affordable costs. Its benefits moved the needle toward better and broader health care coverage for Americans, a forward movement that is in peril as the U.S. Supreme Court this month is expected to rule in a case that could end ACA health-insurance subsidies for millions of Americans.

One year into its implementation, the ACA success is significant. The rates of uninsured fell from 18 percent to 10 percent more in states that expanded Medicaid (7 percent versus 14 percent). More people approve of the ACA (43 percent versus 42 percent); 81 percent of those enrolled in ACA plans are satisfied with their coverage; insurance rate premiums are lower; and health-care spending is lower than previous estimates.

As expected with large-scale endeavors, the ACA encountered unintended consequences; for example, the Medicaid expansion. Under the ACA, people with annual incomes below the poverty line (less than $24,250 for a family of 4; less than $11,800 for individuals) were to be covered by the ACA Medicaid expansion; those with higher incomes (up to 400 percent of the poverty line) were eligible for government subsidies to cover part of their insurance. In 2012, the Supreme Court allowed states to opt out of ACA Medicaid expansion. An unfortunate consequence is that in states that did not expand Medicaid, people below the poverty line became ineligible for government subsidies or expanded Medicaid care. This and other unforeseen problems can be remedied with additional legislative measures.

Medicaid expansion under the ACA continues to be intensely ideologically debated, ignoring a rationale analysis of what is compassionate, humane and good for Americans. Texas had the highest rate of uninsured in the U.S. - 30 percent; 6 million people. Texas has recently tabled Medicaid expansion. Today, millions of vulnerable Texans continue to seek delayed and interrupted care (rather than preventive and continued care) in the emergency rooms of safety-net hospitals. Such care is suboptimal, harmful, costs lives and is more expensive as taxpayers, the insured and employers (who offer health benefits) end up paying for this.

Accepting Medicaid would infuse the Texas health-care system with nearly $90 billion over 10 years, boost economic output by $270 billion, create nearly 200,000 jobs, provide additional insurance to millions of Texans and save thousands of lives. The American Society of Clinical Oncology adopted the expansion of Medicaid as its official position. Despite the Medicaid issue, ACA implementation in Texas has already showed positive effects. Even as the state holds the highest rate and number of uninsured, the percent of uninsured adults (age 18 to 65 years) fell from more than 25 percent to 17 percent under the ACA.

A looming health-care disaster over Texas relates to the special arrangements with the Centers for Medicare and Medicaid Services (CMS) to receive extra federal money to help hospitals legally bound to provide care to patients who cannot pay. These "uncompensated-care pools" (involving nine states, including Texas) are subject to periodic renewals. The CMS informed Florida, the first state to be reviewed for renewal, that the federal funding will lapse at the end of June unless the state accepts Medicaid expansion under the ACA. Should this come to pass in Texas, it would spell financial and health-care disaster.

Former Texas Gov. Rick Perry turned down the ACA Medicaid funding. We hope that Gov. Greg Abbott will hear the pleas of multitudes of health-care providers and experts, and accept the ACA Medicaid expansion before the health-care hurricane crisis hits Texas.

Kantarjian is the Baker Institute Scholar in Health Policy and Chair of the Department of Leukemia at the University of Texas M.D. Anderson Cancer Center. Ho is the James A. Baker III Institute Chair in Health Economics, a professor in the Department of Medicine at Baylor College of Medicine and a professor in the Department of Economics at Rice University.