Op-Ed: Abrami: Medicaid Expansion not worth the risk

The N.H. Legislature has an important vote on Medicaid expansion coming up soon. As a state representative, I have one of those votes, which I take very seriously. I have been monitoring the progress of the Medicaid Expansion Commission and presented testimony concerning issues I need addressed. As a thoughtful legislator, I am searching for a reason not to vote “no.”

The real issue to me is, will the Medicaid expansion program place New Hampshire in financial jeopardy in the future? These are some of the thoughts that are going through my mind:

1. The Affordable Care Act was not bipartisan. There were no Republican “yes” votes in the U.S. House or Senate (there were 34 “no” Democrat votes in the House). What I do know is that all great legislation has historically had some bipartisan support. During the 1965 Medicare vote, 50 percent of the Republicans in the House voted “yes,” along with 41 percent of Republican senators. As for the Democrats, “no” votes were cast by 10 percent of senators and 16 percent of House members.

2. Those who voted “no” probably understood that estimates that Medicare would cost $9 billion a year by 1990 were bogus. They were correct. Medicare actually cost $98 billion in 1990.

3. Why is that, you ask? Well, I remember President Jimmy Carter’s Secretary of Health Education and Welfare Joseph Califano saying, “You can never get enough health, education and welfare.” One of the laws of political physics is that when something is perceived to be free, that something always will be consumed at a faster rate than predicted.

4. In the case of the ACA, the original cost projection over 10 years was $900 billion, half to be funded by tax increases and half by Medicare cuts. Those in the know understood the Congressional Budget Office must score based on the next 10 years. At that time, they factored in 10 years of tax increases, but only six years of expense because the program rolls out in 2014. The 10-year cost projections from 2014-2023 are $2.6 trillion. History repeats itself.

5. The question is, can the country afford the ACA? It would be one thing if the United States were in great fiscal health, but we aren’t. The national debt is $17 trillion. This is money we spent that we have borrowed. The less-reported issue is the $125 trillion unfunded liability for Medicare, Social Security and prescription drug programs. This is money that we have to pay out some day and have no idea where it will come from. Don’t forget the continued quantitative easing program by the Fed at a rate of $85 billion a month that continues onward.

6. There are 25 states that have chosen not to join the Medicaid expansion program, primarily because they do not trust the promises made by the U.S. government to pay 100 percent and then 90 percent of the costs (after three years). If the federal government reneges on its promise to pay and New Hampshire is forced to pick up the tab, it will be politically impossible to vote this type of program out. How will we pay for this? An income tax?

7. I had a chat recently with a ranking executive of the American Hospital Association. It endorsed the ACA only two days before the vote because it had major concerns. Now it is bemoaning all the cuts facing its institutions. I simply said, didn’t you know “affordable” meant “cuts?” Look at the Cleveland Clinic, which President Barack Obama touted as an example of a low-cost model of health care delivery (it actually is, from my experience), which just announced $300 million in operating costs would need to be trimmed because of the ACA. So, the Cleveland Clinic, which actually cares for patients, needs to cut, while the Internal Revenue Service and other federal agencies are adding thousands of jobs to administer the ACA. There is something wrong with this.

8. We see the AFL-CIO is upset with what the ACA will mean to its members; giant United Parcel Service announces 15,000 spouses of workers who can obtain insurance elsewhere will be forced off their current plan; Walgreens is forcing its 160,000 employees onto the exchanges; SeaWorld is moving its part-time workers from 32 hours to 28 hours; the Manhattan Institute says that of the 14 states that have reported thus far, there has been a 24 percent increase in health care premiums; and so many thousand more examples of companies changing behavior in ways that were not anticipated. The ACA is resulting in higher health insurance costs, people being forced off their current insurance carrier, and people being forced to change doctors and hospitals, all things President Obama said would not occur.

9. Then there is New Hampshire’s health insurance exchange with one insurer Anthem (which is sad in its own right) dictating those covered by the exchange cannot go to 10 of our 26 hospitals. That speaks for itself.

All of these above points make me nervous that the ACA is, indeed, a train wreck, to quote Sen. Max Baucus. Yes, we have a very inefficient health care system (I have been saying this for years) caused primarily by incentives that work counter to quality care at an appropriate cost. Unless the Medicaid Expansion Commission can prove with near 100 percent certainty that New Hampshire will not be placed in financial jeopardy in the future, I will be a “no” vote. In my humble opinion, this bureaucratic nightmare, with its nearly 20,000 pages of regulations and the IRS as traffic cop, is not the answer we needed. I am willing to work with my Democrat friends to fix our health care problems. But thanks to the U.S. Supreme Court’s ruling, New Hampshire does not have to be a party to the financing of what appears to be an ill-conceived program. If we vote down the ACA, New Hampshire citizens with incomes between 100 and 138 percent of the poverty level can still go to the exchange and get a policy. Go to the Kaiser Foundation Web site, www.kff.org/interactive/subsidy-calculator, and see the significant federal subsidies they will receive, which I pointed out to the Medicaid Expansion Commission. Federal money is still our money, but as a state representative, if I vote “no,” I will at least be minimizing the financial risk to New Hampshire.