June 23, 2018
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How LePage proved smokers, drinkers should get Medicaid

Nick Sambides Jr. | BDN
Nick Sambides Jr. | BDN
Gov. Paul LePage high-fives with a bystander as he walks in Brewer during a Fourth of July parade on July 4, 2013.


Gov. Paul LePage on Monday continued his broadside against an expansion of Medicaid under the federal Affordable Care Act, issuing a news release claiming that expanding the public health insurance program for low-income people “will mainly benefit younger men, smokers and drinkers.”

The policy battle over Medicaid expansion is finished, for now, and LePage was able to claim victory when he vetoed an expansion bill that passed the Democrat-controlled Legislature. But the public relations war is not over, and that’s why neither opponents nor supporters of the expansion can let the topic go.

His Monday news release cited a study in the latest issue of the Annals of Family Medicine that predicts the health characteristics of those most likely to gain Medicaid coverage. Indeed, those likely to gain Medicaid eligibility on Jan. 1 are more likely to smoke, more likely to drink heavily and more likely to be young and male than the current crop of Medicaid recipients.

By highlighting those findings, LePage is playing to a natural aversion among taxpayers to providing a government service to those who are able-bodied and make irresponsible life choices. But the study he cites actually makes the case that covering this newly eligible population is a wise investment.

Some 49.2 percent of new enrollees are likely to be smokers, and 16.5 percent are likely to describe themselves as heavier drinkers. Among current Medicaid recipients, those numbers are 38 percent and 9.8 percent respectively. Medicaid recipients are about 50 percent more likely to smoke than the general population, according to the U.S. Centers for Disease Control and Prevention.

A closer look at the study’s projections provides a clearer picture of the health of newly eligible Medicaid recipients. They’re more likely to be in good and excellent health than the current Medicaid population, less likely to be obese, less likely to suffer from depression and about as likely to suffer from hypertension and diabetes.

The study concludes Medicaid will likely spend less per recipient in the short term to cover this new population, and it actually recommends providing them with coverage. “Given the higher prevalence of tobacco smoking and alcohol use,” the study’s authors write, “broad enrollment and engagement of this potentially eligible population is needed to address their higher prevalence of modifiable risk factors for future chronic disease.”

As lawmakers this past spring debated whether Maine should expand Medicaid, GOP legislators often argued Maine should tend first to elderly and disabled residents placed on waitlists for services such as group homes, in-home care and work support before extending coverage to low-income but able-bodied residents.

LePage made the same argument Monday. But in pointing to a reason why Maine shouldn’t extend Medicaid coverage to about 50,000 adults without children — the expansion would also prevent about 25,000 other low-income parents and childless adults from losing coverage on Jan. 1 — he actually pointed out why Maine should expand Medicaid.

Without insurance coverage, the newly eligible Medicaid population wouldn’t have the means to pay for smoking cessation medications and alcohol misuse counseling, Medicaid-covered services that can prevent minor health problems today from becoming more costly health issues in the future. A study of Medicaid in Massachusetts found its smoking cessation program returned $3.12 to the program in medical savings for every $1 spent.

And under the Affordable Care Act, the federal government would cover 100 percent of Medicaid costs for new recipients for three years and ratchet down to 90 percent of costs — higher than Maine’s current 62.57 percent federal funding rate — by 2020. Maine would spend fewer state dollars than it’s currently spending in the early years of the expansion.

Opponents of the expansion have questioned whether the federal government will stick to its funding promises, but in the nearly five-decade history of Medicaid, the federal government has stuck to its predetermined funding rates.

Opponents also question where the additional, long-term state investment will come from to cover new populations with Medicaid. There are certainly areas to cut Medicaid costs, which account for about a quarter of the state budget. Maine spends more than the national average per Medicaid recipient — $8,077 compared with $6,826 in 2009, according to the federal Centers for Medicare and Medicaid Services.

And Mary Mayhew, the LePage administration’s Health and Human Services commissioner, is right to pursue initiatives expected to trim Medicaid costs, including pushes to pay health care providers for outcomes rather than procedures, efforts to home in on the most expensive Medicaid recipients and trim their health care consumption and initiatives to provide the elderly and disabled with cheaper services at home rather than sending them to expensive nursing homes and institutions.

There are also cost reduction lessons to learn from health care providers in Maine. Medicaid recipients are more likely to seek expensive care in hospital emergency departments than those with private insurance and those without insurance. But some areas of the state see significantly lower emergency department use among Medicaid recipients than others. Perhaps Maine can take some lessons from those areas with lower emergency room use.

While an expanded Medicaid program would inevitably cover residents who smoke and drink more, an expanded program would also give Maine the opportunity to help those residents turn around their habits and avoid running up the tab down the road.

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