So… The General Assembly has enacted Medicaid reform. That’s a big win for Governor Ralph Northam and Virginia Democrats, and potentially good news for 400,000 of near-poor Virginia adults who now will qualify for a healthcare program that will be 90% funded by the federal government and 10% by the state. It’s not such good news for budget hawks concerned about Medicaid’s runaway impact on Virginia’s General Fund budget or for patients who could pick up the tab for a new $300 million-a-year assessment on hospitals.

The reporting on Medicaid expansion, the biggest entitlement expansion in recent Virginia history, has been truly dreadful — a fact that I attribute to the downsizing of newsrooms across Virginia and the resulting inability of Virginia media to field the manpower to do anything more than cover General Assembly hearings. It is astonishing how little we really know about the impact this legislation will have on the cost and delivery of health care in Virginia.

My big questions now: (1) Will the program improve the health of Virginia’s near poor; (2) will it do so within the budget constraints that have been promised; and (3) how much of the cost, if any, will get passed on to the privately insured?

In all likelihood we will never know. That’s because no one appears to have identified benchmarks by which the effectiveness of the legislation can be measured. The politicians, activists and pundits will declare victory and move on to the next cause of the day. The last thing they want is to lay down markers by which this entitlement expansion can be judged to be effective or not. We don’t have the capacity here at Bacon’s Rebellion to do that heavy lifting, but we  can ask questions that are worth bearing in mind as the Medicaid juggernaut rolls forward.

Budget savings. A key promise in getting Medicaid expansion enacted is that the program will pay for the state contribution through savings in state programs. In theory, the Commonwealth will save $370 million in prison healthcare, mental health, indigent care funding, FAMIS pregnant women, and the like, over the next two-year budget. Will those savings materialize? I’m fairly confident that they will — budget items like this are among the easiest things to predict. But we won’t know for sure if we don’t check.

Impact on the Affordable Care Act. Steve Haner noted in a previous post that an estimated 60,000 Virginians now covered by Affordable Care Act health plans will be enrolled in Medicaid. What does it say about Medicaid expansion if, to a significant degree, it is just shifting tens of thousands of patients from one government-subsidized program to a different government subsidized program? Another question: Does Medicaid provide better coverage than Obamacare or worse? Yet another: What actuarial impact will the loss of 60,000 patients have on the Obamacare plans?

Speaking of Obamacare… The Affordable Care Act insurance markets continue their meltdown in Virginia. According to HealthInsurance.org, the weighted average of next-year rate increases filed by all insurers in Virginia is 13.4%. Some fraction of that increase can be attributed to Trump administration actions, but the markets also have been in a death spiral in which healthy patients bail out, forcing insurers to hike rates to cover the remaining, sicker patients. Regardless of who or what is to blame, it is difficult to appraise what is happening in the Obamacare markets. Plans vary so widely by the amount of deductibles and discounts negotiated from listed prices that it is impossible to compare Plan A with Plan B. The situation could be worse than it appears from comparing premiums alone. What will happen to the near-near poor (as opposed to the near-poor enrolled in Medicaid) if they get priced out of the market? Will Medicaid have to expand to cover them, too?

Quality of Medicaid care. Medicaid reimburses hospitals and doctors at the lowest rate of anybody in town, and most providers lose money on their Medicaid patients. Combine that with an acute shortage of doctors, and you get a situation in which it is exceedingly difficult for Medicaid patients to find primary case physicians. The General Assembly has done nothing to alleviate the doc shortage. Perhaps the managed care plans set up for Medicaid patients will devise work-arounds for the problem. Perhaps not. Nationally, there has been considerable debate about whether Medicaid patients are better off with Medicaid than if they just threw themselves upon the mercy of hospitals and doctors. Inevitably, that debate will be reprised here in Virginia. The Northam administration should settle upon metrics that track outcomes for Virginia’s near-poor population before and after Medicaid expansion.

Cost shifting. The financing of the health care system is stacked against the middle class. Hospitals shift a portion of the cost of treating their money-losing patients (indigent, uninsured, and Medicaid) to patients with privately insured health plans. Privately insured patients could get a triple whammy next year. Not only will they pay higher premiums due to general health care inflation (the first whammy), but they’ll eat the estimated $300 million hospital assessment enacted as part of Medicaid expansion (the second whammy). Plus, they could take another hit as docs and hospitals treat more money-losing Medicaid patients and shift costs to the privately insured (the third whammy). On the other hand, Medicaid expansion will inject a couple billion dollars into the system, so maybe cost-shifting pressures will diminish. Frankly, nobody knows. But it would inform future debate if someone tracked the numbers and performed the analysis.

Hospital profitability. With the exception of some rural hospitals, putatively nonprofit hospitals have consistently maintained high levels of profitability through the twists and turns of health care markets over the years. Will Medicaid expansion pad or diminish their profitability? I’m predicting that overall industry profits in Virginia will surge, but I could be wrong. Again, it would be helpful if someone kept track so we can understand what’s happening.

I offer this list just to get the conversation started. I’m sure readers can refine the thinking. What’s important is that we start measuring now. I would hate to find ourselves revisiting Medicaid expansion two or three years knowing no more than we do now.