The ACP Advocate Blog

by Bob Doherty

Thursday, January 14, 2010

Why do red states gain the most under health reform?

With news that a tentative deal may have been reached on the contentious issue of a tax on high cost health plans, the negotiations on the health reform bill may be on the verge of overcoming one of the biggest obstacles to reconciling the House and Senate bills. It looks increasingly likely that the House and Senate may strike a deal to allow a revised bill to be sent, as early as tomorrow, to the Congressional Budget Office, for a revised estimate of its impact on the federal budget. This would set the stage for possible passage of the legislation by the end of this month or early February.

Without assuming anything, it isn't too soon to begin talking about who gains and who loses under the likely compromise legislation. Writing in the Health Affairs blog, Claudia Schur and Marc Berk estimate that "the states most likely to 'win' as a result of health care reform are Arkansas, Idaho, Kentucky, North Carolina, Oklahoma, Tennessee, and Utah. All of these states have a relatively high number of uninsured and all are in the bottom half of states in terms of cost under both financing mechanisms." They used a simple metric - "benefits were measured in terms of the state's current proportion of uninsured residents, and costs were assessed by ranking the states to see which would be hardest hit by each of two financing mechanisms, a tax on high earners and a tax on high health insurance premiums" - to determine which states would get more benefit than their contribution to the cost.

"Among the states most likely to 'lose'" they write, "are Delaware, Nebraska, and New Hampshire as well as the District of Columbia. Each of these states has a relatively lower-than-average proportion of uninsured residents, and each would fall in the "High Cost" category under either of the financing options." Other states would do better or worse depending on which financing mechanism - tax on high income residents or tax on high cost insurance plans - is used. Many other states fall somewhere in between.

What do the "winning" states have in common? They have more uninsured persons, fewer unionized workers, lower average insurance premiums (meaning fewer "Cadillac" plans to be taxed), and fewer high income persons (meaning fewer people who fall in the income brackets that may have to pay higher taxes). "The overall pattern therefore shows a curious alignment" they write since, "states with the most to gain under health care reform are overwhelmingly represented by Republicans, while those states likely to do worse are much more likely to have Democratic senators."

This dissonance between a state's partisan voting pattern and how much they will gain is dramatic: "When we examine the seven states most likely to be winners under reform, we see a combined split in their Senate delegations of twelve Republicans versus two Democrats. The three states most likely to lose under health care reform are collectively represented by four Democrats and two Republicans. When we add in the group that would be losers under the income-tax option, the split becomes even stronger, with these states being represented by eighteen Democrats and four Republicans."

If politics was all about bringing home the goods, then one might expect that the states that will gain the most from health reform would be the most in favor of it. But the "red" states that will gain economically from health reform are also the ones whose electorate tends to be most distrustful of government. Because these voters don't particularly like government, they have been willing to tolerate high number of uninsured persons. Now, though they will gain the most if the federal government ends up picking up the tab to cover more people - even though their own Senators (and most of their residents) were against it. Meanwhile, many of the Democratic "blue" states will see more of their tax dollars go to paying for health care coverage in the states that didn't want it in the first place.

The best hope the Democrats have is that once health reform is signed into law, red state voters will eventually discover that they have gained the most from the programs, and may even give the Democrats some of the credit.

Today's question: What do you take away from the dissonance between how much a state will gain from health reform and how little support it has in the state?

4 Comments :

Blogger Wallace Sampson said...

I've wanted to gather the ACP reps in on room and shout, "What are you doing? Can't you back up and see the big picture?"
That picture is the one clearly developing in the darkroom as the administration's true images slowly appear. The President is a trained Marxist, schooled in the Alinsky mode, burnished in the hardnosed political machine that rules Chicago and Cook County and who is conditioned to see the US not as a free country of free people, but as a layered class society run by an elite of bankers and industry captains over a serfdom of the powerless and disadvantaged proletariat.
The ACP approaches "health care reform" as though it were an isolated affair, needing only a few patches here and there, while lobbying to assure physicians'incomes and primary roles.
The reality is that "health care reform" is just one salient in an assult on the US form of government and on the Constitution itself. And, to install a one-party system, or at least a dominant party with a minimized opposition, relegated to minority status for forseeable decades.
Within one year, this president has assumed control over two major automakers; the secondary insurance industry (AIG), investment banking to the point of fining for profita and limiting executive income; much of housing (through FannieMae and FreddieMac loans;) has neutrilized and demotivated the CIA and military; and is generating power and control over the atates through a new 10-governor national council and further control over the National Guard and a hoped for national police force.
Most of these moves are either unconstituional or violate centuries of balance of powers principles.
WS

January 15, 2010 at 1:39 AM  
Blogger Wallace Sampson said...

The reform bils being negotiated establish te federal government as director of fees, conditions of insurance coverage stand although direct federal insurance may be out, a simple bill rider in future years could re-establish that, also.
Most important is the con centration of power in Washington, with enforcement powers throigh the zinternam Revenue Service, fines on non-compliant patients, and eventual cotrol of practice standards as the only way to cost control.
The evil is not the practice standards themselves, but the setting by the central government with the power to fine and imprison. And standards are not that easy to set in medicine - a rapidly changing field with diagnoses and definitions with wide fuzzy edges.
The argment that the US already is involved in health care is not relevant. It is the eventual and intended complete takeover of a free profession that is the threat - and not being addressed. Federal control is rarely released, and almost always expanded over time.
It's time to shout. (And, no, I am not an "inside jobber" or other junkie.)

January 15, 2010 at 2:07 AM  
Blogger Jay Larson MD said...

Ah, the irony of a complex system trying to achieve equilibrium. Does it real matter what the “color” of a State is to receive additional help? If that State needs help, then help them. Arkansas, Idaho, Kentucky, North Carolina, Oklahoma, Tennessee, and Utah should not be excluded from the benefit of health care reform just because there are more Republican voters than Democratic voters.

Even though the Federal health care reform effort is permeated with the stench of partisan politics, it is only the Feds that can turn the direction of health care. Leaving health care to “business” has resulted in the mess that we are in currently. How all this will turn out will only be a guess. I just hope it helps some people that need help.

Hmmmm, helping people in need, now where did I hear about that? Oh yeah, the Hippocratic oath. “I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”

January 15, 2010 at 10:23 AM  
Blogger james gaulte said...

While it is possible that some voters would look at some abstract net aggregate gain for "their" state when whatever bill is finalized passes, but I'll bet more will be concerned abut the well publicized deals(think Nebraska,Louisiana,unions excepted from Cadillac Tax)that were used to push through something in spite of widespread and apparently growing opposition from the public.

January 16, 2010 at 7:32 AM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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