The pros and cons of expanding Medicaid

In 2012, the Supreme Court ruled that Obamacare's provision requiring states to expand Medicaid to cover almost everyone making <138% of the federal poverty level, as opposed to the groups it originally covered: "only low-income children, parents, pregnant women, and disabled persons." As of January 14 of this year, 31 states and Washington D.C. have decided to expand Medicaid, while the rest have chosen not to. In this post, I will discuss the arguments for and against expanding Medicaid.

The pros: 

1. Since the federal government has promised to pay for "100 percent [of this cost] for the first three years, and then declining gradually to no less than 90 percent in future years," if this promise is kept, the states will have to pay for at most only 10% of the cost of expansion.

2. A 2012 study found that "State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health." Another more recent study found that "The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage." 

3. If you choose not to expand Medicaid, your state may end up like Texas, which is eschewing $100 billion of federal money over a decade by doing so, and not insuring over a million people. In addition, the state is spending $5.5 billion per year treating the uninsured, which is being covered by "taxes and insurance premiums paid by the state's businesses and residents, who are also footing the bill for expanding Medicaid in 29 states and the District of Columbia that agreed to accept federal funds to offer coverage to nearly all poor adults." 

The cons: 

1. The key word in the first statement is "if": some conservatives have argued that the next congress might change this provision by "decid[ing] to fund Syrian refugees and foreign worker visas rather than Medicaid" or, if the Fed raises interest rates, "raid[ing] Medicaid and get a few extra billion for interest payments." 

2. Doctors don't get paid as much for seeing Medicaid patients as they do for seeing Medicare patients. Obamacare fixed this by requiring doctors to get paid the same amount for seeing either type of patient, but this fix was temporary, and beginning in 2015, according to the Urban Institute, primary care doctors' Medicaid payments declined by 43%. This led to many doctors not seeing as many Medicaid patients. As the Federalist argued in 2014, "Too often the current Medicaid program denies patients access to care, since about 40 percent of primary care doctors do not even accept Medicaid patients because the reimbursements are so low."

3. Another argument is that, in line with point 2 above, according to Alan Reynolds of the Cato Institute, "Medicare reimbursement rates are far too low to cover the costs of high-quality medical services, and Medicaid reimbursement is even worse." 

4. Another big argument is that the costs of Medicaid borne by the states, although only 10% of the total, are still substantial, and that costs have been much higher than anticipated for the states that have expanded.
5. Medicaid is ineffective at improving health outcomes. This claim is generally based on the Oregon Medicaid experiment, the results of which were published in lots of different journals, including the New England Journal of Medicine in 2013. This study concluded that "...Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain." 

Now to debunk the "cons":

1. This is mere speculation: the only way states would have to pay >10% of the costs more than 3 years after the expansion would be if "Congress passed a law to change the ratio." Also, as the New York Times Editorial Board noted, despite GOP concerns that the federal government might back off from paying 90%, "there is no reason to believe that will happen, and if it does, it can be resolved when it arises." 

2. Putting this claim to the test would require looking at states that have expanded Medicaid and seeing whether more or fewer people are being seen by doctors. As it happens, the Oregon Medicaid experiment (you know, the one cited as proof "Medicaid doesn’t actually improve health outcomes") debunked this claim: one of its authors said that "We can eliminate the story that Medicaid is so lousy you can’t get in to see a doctor" because in the study, "People who gained access to Medicaid did use more health care". 

3. According to the Urban Institute, revenues of hospitals in states that expanded Medicaid would be expected to "increase [by] nearly $300 billion over the 2013-2022 period – a 23% increase in Medicaid reimbursement for hospitals." Besides that, as noted in the point just above this one, people on Medicaid "did use more health care" in the Oregon experiment, and the 2012 study cited in point 2 in the "Pros" section reached similar conclusions. 
4. In reality, it costs more not to expand Medicaid than to expand it. The Kaiser Family Foundation found that states (and Washington DC) "that didn't broaden coverage saw their Medicaid costs rise 6.9 percent in the fiscal year that ended Sept. 30. The 29 states that took President Obama up on his offer to foot the bill for expanding Medicaid saw their costs rise only 3.4 percent." Similarly, a 2013 RAND study found that the 14 states that had, at the time, announced their intention not to expand Medicaid actually refused to do so, they would "collectively will spend $1 billion more on uncompensated care in 2016 than they would if Medicaid is expanded." In part this is because states like Texas that refuse to expand Medicaid still have to spent money ($5.5 billion per year for Texas alone) treating the uninsured--money that the state has to cover with taxes rather than taking billions it from the federal government.
5. See the 2012 study above--you know, the one that found that "State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health", linked here again for your convenience. Now, it's true that the Oregon study reached the opposite conclusion w/respect to outcomes. But this may not mean that Medicaid expansion doesn't work, because the same study found that such expansion was associated with increased "rates of diabetes detection and management, and it reduced observed rates of depression by 30 percent." There are also some limitations to this study, including that it "measured only three health indicators — blood-pressure, cholesterol and glycated hemoglobin levels (which measure diabetic blood sugar control) — and only over a two-year period." Another study estimated that "Medicaid expansion in [Texas] would have resulted in 184,192 fewer depression diagnoses, 62,610 fewer individuals suffering catastrophic medical expenditures, and between 1,840 and 3,035 fewer deaths."

In short, every state that has refused to expand Medicaid should do so as soon as possible, and, as Jon Stewart put it, there's only one real reason to refuse to do so: spite against President Obama. 

Everything you know about Prohibition is wrong

It is very hard to find articles about Prohibition, or even tangentially mentioning it, that don't explicitly say one or both of two things:

1. It didn't work because people kept drinking illegally, and

2. It encouraged organized crime, especially gangsters such as Al Capone.

The two links above are just a drop in the bucket--there are countless other examples of news articles claiming the exact same things. The problem is that both of these premises are either largely or totally wrong.

First of all, Prohibition did lower alcohol consumption. Not only that, but "The lowered level of consumption during the quarter century following Repeal, together with the large minority of abstainers, suggests that Prohibition did socialize or maintain a significant portion of the population in temperate or abstemious [not self-indulgent] habits." Even libertarian economist Jeffrey Miron, along with Jeffrey Zwiebel, estimates that shortly after Prohibition became law in 1920, alcohol consumption fell to about 30% of its pre-Prohibition level, albeit temporarily (it increased to 60-70% of this level over the next few years). By other estimates (by Miron and Angela Dills), prohibition reduced cirrhosis by about 10-20%. 

As for crime, according to a 2006 paper by Jack Blocker, "Although organized crime flourished under its sway, Prohibition was not responsible for its appearance, as organized crime’s post-Repeal persistence has demonstrated." 

So why does it matter whether Prohibition failed or not? Because, as the aforementioned 2006 paper points out, "Arguments that assume that Prohibition was a failure have been deployed most effectively against laws prohibiting tobacco and guns, but they have been ignored by those waging the war on other drugs since the 1980s, which is directed toward the same teetotal goal as National Prohibition." Yet that does not mean people haven't argued that since Alcohol Prohibition was a failure, drug prohibition was too. Take the Drug Policy Alliance, which on December 5, 2013, the 80th anniversary of the repeal of Prohibition, announced that "Eighty years ago today, the Twenty-first Amendment to the Constitution was ratified and alcohol Prohibition was officially repealed. If you only know one thing about Prohibition, it's probably the fact that it was a tremendous failure. Making alcohol illegal led to huge increases in organized crime, corruption, and violence." This argument, however, is founded on a false assumption, because as Blocker notes, "Simplistic assumptions about government’s ability to legislate morals, whether pro or con, find no support in the historical record."

So does this mean prohibition would work if we reinstated it now? Sort of: according to Wayne Hall of the University of Queensland, "It is incorrect to claim that the US experience of National Prohibition indicates that prohibition as a means of regulating alcohol is always doomed to failure. Subsequent experience shows that partial prohibitions can produce substantial public health benefits at an acceptable social cost, in the absence of substantial enforcement."

Now you’re doubtless wondering what “partial prohibitions” are. So was I when I first read the above paper. Apparently, under partial prohibition of a drug, it is legal to possess and use it for nonmedical purposes, or to import, produce, and cultivate it for your personal use, or possibly to give a small amount of it as a gift, or to sell small amounts of it, to someone else. Under this paradigm, it would still be illegal to import, produce, or cultivate the drug for the purpose of distribution (as opposed to personal use), to commercially distribute the drug for nonmedical reasons, or to drive while under its influence.

This seems like the way alcohol is treated now, except that companies can produce and distribute it for commercial purposes. The really appealing part, though, is that this policy encourages:

• Permitting a simultaneous medical, educational, religious, and parental effort to concentrate on reducing irresponsible use and remedying its consequences, and
• Removing the criminal stigma and the threat of incarceration from a widespread behavior (possession for personal use) which does not warrant such treatment.

These two ideas seem to balance the desire to reduce the adverse effects of drug use and avoid stigmatizing and/or arresting and/or imprisoning people who use such drugs.

Gun background checks and the "gun show loophole"

The following recommendation was made by a number of American organizations earlier this year: "[We] strongly support requiring criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, and private sales between individuals. Although current laws require background checks at gun stores, purchases at gun shows do not require such checks. This loophole must be closed."

Which organizations do you think were behind this recommendation? If you guessed a gun control advocacy group like Everytown for Gun Safety, you were wrong. It was actually made by 8 professional medical organizations: American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association, and the American Public Health Association. Also on board is the American Bar Association, which informs us that this and other recommendations do not conflict with the Second Amendment. You can read the whole text of the recommendations here.

Among the politicians who have endorsed the "closing the "gun show loophole"" recommendation made by the above organizations is Hillary Clinton. 

So are they right? Is there a "gun show loophole"? And if so, how important is it to close it as far as reducing gun violence is concerned? In this blog post, I will try to answer the above questions, as well as another: "Would expanding background checks reduce gun violence?"

First of all, it needs to be made clear that the phrase "gun show loophole" applies to more than just gun shows. According to Daniel Webster of Johns Hopkins University, "If you're not a licensed dealer and want to sell a gun directly to somebody, then you don't need to run a background check. Some people call this the "gun show loophole," but it applies to all private sales—including, for example, those that take place over the internet."  

Yet there are those who claim that the "gun show loophole" doesn't exist. For instance, Politico claimed earlier this year that, contrary to Bernie Sanders' claims, "the "gun show" loophole doesn't actually exist. There's nothing in particular about gun shows that allows otherwise illegal gun sales to occur. Sanders instead is referring to an exclusion in the gun laws that does not require a background check in a private sale. It doesn't matter if that sale is at the seller's home or at a gun show, a background check is not legally required." 

They have a point, but not in the way they want their readers to think: the "gun show loophole", although its name is somewhat misleading, does exist. So how is its name misleading? It suggests that the way background checks work is as shown in the chart below (Yes/No refers to whether a background check is required for such sales):

	Licensed gun dealership (e.g. store)	Gun show
Licensed gun dealer	Yes	No
Unlicensed private gun dealer	Yes	No

In fact, as Vox discussed recently, it works more like the chart below:

	Licensed gun dealership (e.g. store)	Gun show	Online sales	Home sales
Licensed gun dealer	Yes	Yes	Yes	Yes
Unlicensed/private gun dealer	N/A	No	No	No

The above situation arises because if you are a private gun dealer, you can be unlicensed because "the law does not require a dealer’s license for private hobbyists and others who occasionally buy and sell guns for the purpose of enhancing or liquidating a collection." In contrast, if you repeatedly sell guns mainly to make money, you do need a license, regardless of whether you sell them in a store, at a show, or online. This matters because all licensed gun dealers must conduct background checks. 
So now we've established that there is a loophole as regards gun background checks, but it's not properly called the "gun show loophole" but the "private sales loophole." Now we can move on to the question of whether increased background checks would save lives.

On this front, there is some evidence the answer might be yes, but studies supporting this conclusion have often acknowledged that there could just be correlation, not causation. For instance:

• Sen et al.: "More extensive background checks prior to gun purchase are mostly associated with reductions in firearm homicide and suicide deaths. Several study limitations are acknowledged, and further research is called for to ascertain causality."
• Ruddell et al.: "...states with less stringent background checks on firearms purchases were significantly associated with firearms homicides."

Another study said that the best way to conduct background checks is at the local level, or, to wit, "Using local-level agencies to perform firearm background checks is associated with reduced rates of firearm suicide and homicide." 

To be fair, there are studies showing that background checks don't work, as in the case of the Brady Act of 1994. A 2000 study showed that "Based on the assumption that the greatest reductions in fatal violence would be within states that were required to institute waiting periods and background checks, implementation of the Brady Act appears to have been associated with reductions in the firearm suicide rate for persons aged 55 years or older but not with reductions in homicide rates or overall suicide rates. However, the pattern of implementation of the Brady Act does not permit a reliable analysis of a potential effect of reductions in the flow of guns from treatment-state gun dealers into secondary markets."

In other words, it's possible that the Brady Act only failed because it didn't affect all states, rather than the more obvious conclusion, that strict gun laws don't work.

Also, here's a fun fact: background checks prevent some people with extensive criminal records from buying handguns, but not those whose record consists only of minor offenses, despite the fact that such people are at a much higher risk of committing crimes than others. This suggests that expanding background checks not in terms of which sales they cover but in terms of who they prevent from buying a gun may be a good idea.