President’s Column, February 2025
The Case for Medicaid Expansion in Tennessee
For the past year, we have been studying the need for Medicaid expansion in Tennessee. LWVOR Member Dr. Bill Culbert makes an excellent case concerning why we should continue pressing forward until we achieve the change so badly needed. Thank you, Dr. Culbert, for your timely words as we move into this new year. Carolyn Dipboye.
Expanding Medicaid to all the states was part of the Affordable Care Act of 2010, but a Supreme Court Challenge in 2012 made it an optional decision. Tennessee is one of only 10 states that has not accepted this option, and in doing so is forgoing a billion dollars in federal aid this year and denying almost half a million Tennesseans affordable health insurance.
The club of 38 rich nations except for the U. S. all have universal or near universal health coverage for their populations. Despite spending significantly more per capita than all these nations, according to the World Health Organization, our system is ranked near the bottom in overall performance including standard measures of life expectancy after age 65 and infant and maternal mortality.
A recent Yale study showed that if the U.S. had a single payer healthcare system, in 2020, an additional 212,000 lives would have been saved and in a non-pandemic year, it would save 438 billion dollars-- about ten times Tennessee’s annual budget.
The leading cause of death in the world is hypertension. It is responsible for half of all heart attacks. In the U.S. heart disease has been the leading cause of death since the 1950s and is responsible for about half of all deaths. Despite being easy to diagnose and inexpensive to treat, about 60% of hypertension in the U.S. is undiagnosed or under treated, up from 44% just over ten years ago. With 26 million Americans without health insurance, instead of paying as little as $200 a year for treating hypertension, we pay the cost of the preventable heart attacks, end-stage renal failure, and congestive heart failure. For example, dialysis may cost $90,000 a year for life and congestive heart failure is one of Medicare’s five most expensive diagnostic related groups that we all pay for with our tax dollars.
About 5% of patients are responsible for half of all medical costs. Most of these are the result of chronic disease that is often easily preventable. Regardless of the moral issue of providing preventive care to all our citizens, its denial is economically stupid.
Acting as competing profit centers, there are many players in the system that are responsible for squandering our healthcare dollars, but the major ones are our uniquely for-profit insurance industry, consolidated hospitals, a multinational pharmaceutical industry, pharmacy benefit managers, medical device manufacturers, and in many cases medical specialists themselves.
Before the Affordable Care Act (ACA), the average private health insurance company kept 25% of the healthcare dollars for performing a mere accounting role. Medicare does this for 2%. Over a twenty-year period, the number of corporations that own two or more hospitals has increased from half to two thirds. Ownership of more than two hospitals provides no additional benefit to patients and costs have increased 6% a year while objective measures of quality have declined.
Prescription drugs in the U. S. cost almost three times as much as in 32 other countries. Almost a third of the costs are for 8% of patients with many much cheaper options available.
Pharmacy benefit managers make cost splitting deals with pharmaceutical companies that generate huge profits while providing small cost savings if any for customers, and virtually no value-added service is provided. Expensive medical devices like prosthetic hips are products of a cartel. Having a hip replacement in some Western European countries like Belgium with similar outcomes to a quality U. S. facility including rehab and travel costs from America may be only as much as the prosthesis alone in this country.
Some medical specialists like cardiothoracic surgeons, orthopedic surgeons, interventional cardiologists, some ENTs, maxillofacial surgeons, plastic surgeons, and dermatologists that do a lot of Mohs procedures for skin cancer may make a million dollars a year or more. Hospitals increasingly gravitate toward providing these services because of their own facility profits and limit low-reimbursement services like drug rehab or psychological counseling that have high value for patients and society.
Primary care providers in America see half of all patients each year but garner just 5% of the healthcare dollar, or about a third of that allocated in other high-income nations. Hospitals that see 8%, are responsible for almost a third of all healthcare spending.
This house of cards can easily be pushed down and replaced with a more affordable and equitable system by expanding Medicaid in the state. With the crucible of adjacent states that have taken this option, we see many down-stream benefits with much lower rates of rural hospital closures, higher rates of individual health, lower rates of expensive emergency department usage, higher rates of work attendance, lower rates of drug addiction, more academic achievement, lower rates of criminality, lower rates of child poverty, smaller government, and more business investment as well as expansion of non-healthcare sector jobs.
We should all encourage our state legislators to grab this low-hanging fruit for the public good.
William Culbert, MD