With Governor Terry McAuliffe making another bid to expand Medicaid via a budget amendment, the publication by the StatChat blog ten days ago of data on the extent of insurance coverage in Virginia couldn’t be more timely.
The blog post is content to present the data with little commentary or explanation of what’s happening, however, so I’ll try to fill in the gaps.
The good news is that in Virginia, more than 90% of the population has some form of insurance (including Medicare and Medicaid). The bad news is that 9.1% of the population still has no insurance coverage. And, despite a lower unemployment rate and a higher median household income than the national average, the percentage of the insured population hovers just at the national average.
By eyeballing the chart above, we can see that Virginia’s uninsured population bounced around the 12% mark for several years, then jumped ahead one or two percentage points after the implementation of the Obamacare health exchanges. One also can surmise that some states leaped ahead of Virginia in the rankings by extending Medicaid to the working poor while the General Assembly rejected the option.
These data would seem to back the McAuliffe narrative on the desirability of expanding the Medicaid program, 90% of the cost of which would be paid for by the federal government. If Virginia added just 5% of the population to the Medicaid rolls, the state would have a higher rate of insurance coverage than all but five states.
But dig a little deeper, and the picture gets more complicated. The chart above breaks down those with and without health insurance by age. Roughly two-thirds of the uninsured population is below 45 years old. This younger demographic segment tends to be considerably healthier than the older age cohorts, and its medical needs correspondingly less. Indeed, thousands likely opted out of the Obamacare exchanges because they did not need or want the coverage at the price it was available. Although we can’t tell from this data how many opted out, it is worth noting that some portion of Virginia’s 10% uninsured population is voluntarily uninsured.
Finally, it’s worth studying the map above, which shows the variation in the uninsured population around the state. (I would refer you to the interactive map at StatChat for details.) The uninsured rate in the working-age 18-to-64-year-old age cohort varies from 32.3% in the city of Manassas Park to 4.6% in the nearby city of Falls Church. Clearly there is a link between income, unemployment and insurance coverage. One could argue that the best antidote to uninsurance is a strong economy and high employment; if we want more people covered by insurance, perhaps we should be investing state funds in making people more employable.
But other factors are at play, although I’m not sure what they are. Why, for example, do the Interstate 81 corridor localities of Roanoke, Botetourt and Montgomery counties — not exactly known for a booming economy — have such low percentages of working-age uninsured? Are there unique institutional forces at work? It’s worth looking into.
Bacon’s bottom line: The debate over health care has gotten hung up on the number of uninsured. But that number is almost meaningless without considering the quality of the insurance programs.
For example, thousands of Virginians are “insured” through Medicaid. But what quality of care people do people receive when low reimbursement rates discourage 22% of Virginia physicians from participating, according to a 2016 Physicians Foundation survey? What percentage of Medicaid patients, unable to find a personal physician, routinely get their health care in hospital emergency rooms? And how does the quality of care compare to that provided uninsured people who go to emergency rooms and have their expenses written off as “charity” care or “uncompensated care”?
Another example: Thousands of Virginians have coverage through Obamacare health care exchanges. But what kind of access do they enjoy? Are they restricted to certain hospitals and physicians? How high are their deductibles and co-pays? To what degree, as a practical matter, has the quality of their health care improved? Likewise, how many Virginians forced into Obamacare lost their old insurance policies, how many lost access to their physicians, and how many perceive that they have worse insurance coverage than they had before? Nobody is generating that data.
One more point: How extensive is the safety net for the uninsured in Virginia compared to that in other states? Virginia has a fairly robust system of clinics that provide primary care to the uninsured and under-insured. How many people are getting at least some of their medical needs met through these clinics? How many are slipping between the cracks? And what happens to clinic patients when they require treatment unavailable at the clinics?
Counting the percentage of the “insured” population provides a rough measure of access to the health care system. But there’s a lot it doesn’t tell us. Before undertaking a massive expansion of Medicaid at considerable fiscal risk to the commonwealth, we need a keener understanding of how Virginia’s health care system functions. We should not blindly accept the proposition that an expanded Medicaid program will improve real-world access to the uninsured. While the StatChat data is valuable for starting a discussion, it does not purport to tell us all we need to know.
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