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On the Third Hand: Two PPACA worlds

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One of the strangest things about the Patient Protection and Affordable Care Act (PPACA) is watching a law that — whatever its many faults in design and implementation — incorporates many middle-of-the-road concepts that divide America.

I used to get press releases from chambers of commerce in states like Georgia (!) about how great private health insurance purchasing cooperatives (exchanges) would be for businesses, and, in some cases, how great government-run health insurance purchasing cooperatives (public exchanges) would be for individuals.

Some Republicans were at least open to the idea of creating new restrictions or, maybe, a “public reinsurance program” (translation: a subsidy tax so complicated that no ordinary voters would notice that it was a tax) to help health insurers reduce use of medical underwriting.

Even in the health insurance industry itself, who except for very hard-headed actuaries is thrilled about broad use of medical underwriting in health care finance? Who wants to tell a 25-year-old with leukemia, “You used your $2,000 per month income to pay for food and rent instead of insurance. No chemo for you!”?

Now, the Commonwealth Fund has come out with survey results that illustrate some of the ways PPACA is dividing the country. Many states with Republican governors have refused to take PPACA Medicaid expansion money. 

Defenders of the expansion program argue that offering Medicaid access to low-income, childless adults is the right thing to do, and that it may reduce and rationalize overall health care costs, by reducing uninsured adults’ reliance on charity care, emergency room care, and care for severe health problems created or exacerbated by lack of access to ordinary preventive and urgent care.

Critics say PPACA drafters used funny federal money to fund expansion, and that, however nice Medicaid expansion might be, the money will soon run out, leaving states to deal with unrealistic expectations, and, possibly, higher health care services costs created by the sudden inflow, and sudden outflow, of funny money.

Time will tell a good story about all of that in a few years.

Right now, Commonwealth Fund figures are telling a story about uninsurance rates in Red States and Blue States.

Before the first PPACA World open enrollment period started, 28 percent of the residents in the Blue states and other states that expanded Medicaid were uninsured, and 38 percent of the residents of Red, non-expansion states were uninsured.

Today, the percentage of “expansion state” adult residents who are uninsured has dropped to 17 percent, and the share of non-expansion state adult residents who are uninsured has crawled a little lower, to 36 percent.

The gap used to be 10 percentage points — 10 percent of U.S. adults. Today it’s 19 percentage points.

Probably because of some combination of views about PPACA and geography, there’s also a huge gap between how PPACA World has affected Democrats and how it’s affected Republicans.

The share of Democratic Commonwealth Fund survey participants who reported being completely uninsured fell to 13 percent this spring, from 18 percent in the fall.

The share of Republican participants who are uninsured held steady at 11 percent.

On the one hand: I think demagoging either expansion or non-expansion states about their decisions is premature. 

Even if more people in expansion states have coverage, for example, that doesn’t mean the new coverage will necessarily work at all as expected; that access to coverage will necessarily lead to improved health outcomes; or that the coverage expansion programs are sustainable.

Conversely, there’s no guarantee that the non-expansion states will come out ahead in terms of raw savings, budget efficiency, or economic realism or freedom.

Maybe some non-expansion states could end up with as much, or more, state and federal government spending and market-distorting regulation and corruption as the expansion states.

Maybe some non-expansion states will tell all sorts of lies to themselves to keep themselves from having to face the fact they, too, end up with plenty of health-related government activity, whether that be through imposing health care “user fees” that are actually taxes, paying to put a higher percentage of poorly nurtured young adults in prison, or spending more on foster care for the children of parents who died young.

On the other hand: The idea that PPACA is actually widening the health coverage access gap between ultra-healthy states like Minnesota and unusually sickly states like Louisiana is stunning. The fact that it’s leading to big increases in coverage levels for Democrats, and not for Republicans, is also stunning.

Whether the increased coverage levels for some are durable or temporary, or the new coverage ends up working well or poorly, what does it mean, fall election-wise, for the Texans living along the Texas-Arkansas border to see that Texans are now about twice as likely as residents of Arkansas to be uninsured?

On the third hand, this will be a great time for economists. They will get great comparison data about what access to health coverage means for public health and general economic productivity. Towns that straddle the Texas-Arkansas border and the Pennsylvania-West Virginia border might be interesting places to start.