Some of the nation's largest cities could reduce their uninsured population by more than half if their state lawmakers would relent and accept Medicaid expansion funding under Obamacare. That's the conclusion of a new study from the Urban Institute and Robert Wood Johnson Foundation.
The study looked at 14 diverse, large cities, seven of which are in states that are expanding. The number of uninsured people in those cities should drop by an average of 57 percent. In the non-expansion states, that decline will average 30 percent. Detroit, in expansion state Michigan, will see a 66 percent drop while Atlanta, will see just a 25 percent reduction. That speaks to the significance of the "woodwork" effect—people who discover they're eligible for Medicaid through the application process for insurance and through stepped-up outreach efforts. But those cities are missing out.
The cities that are really being hurt: Memphis, Miami, and Philadelphia where more than half of the population in each would be eligible for Medicaid after expansion. The pain goes beyond the people left uninsured, the report concludes, and has larger social and economic ramifications as well.
Cities in states not expanding Medicaid would face other challenges in addition to having more uninsured residents and foregoing additional revenue. There will be reductions in Medicare reimbursement and Medicare and Medicaid disproportionate share hospital payments under the ACA, which could be particularly difficult for urban safety-net providers serving uninsured people across a wider region. Also, many states require counties to maintain indigent care programs or pay part of the costs of Medicaid.Not coincidentally, those are the populations that Democrats need to get to the polls in 2014. Here's a very good issue to help make that happen.
Differences in the impact of the ACA on cities also reflect a wide diversity in income, immigration status, and race and ethnicity. For example, nearly two-thirds of the uninsured in Detroit have incomes below 138 percent of the federal poverty level, compared with only 38 percent in Phoenix. Nearly 80 percent of the uninsured in Miami are Hispanic, while more than three-quarters of the uninsured in Detroit are non-Hispanic blacks.