Obamacare is many things. One of which is an interesting natural experiment in determining whether states shooting themselves in the foot makes it harder or easier to walk than states that don’t shoot themselves in the foot.
When PPACA passed in March 2010, the basic cash flow model would have seen increased taxes (income tax surcharges, Cadillac plan taxes, medical devices, tanning tax etc) from richer and usually bluer states as well as Medicare Advantage clawbacks from a variety of places. The Medicare Advantage clawbacks would apply to everyone but areas with higher Medicare Advantage utilization would see greater net reductions. This money, either new from taxes or reprioritized from Medicare Advantage would then go pay for either Medicaid expansion or coverage/cost-sharing subsidies. Regions with very low pre-PPACA Medicaid eligibility thresholds and high uninsured populations such as Mississippi would see more new Federal money than states with high Medicaid thresholds and low uninsured populations like Massachusetts. Massachusetts would pay more and proportionally get less back. That is expected, it is how every single social welfare program in this country works.
There are two natural experiments in action now and a future potential experiment in cash flow modeling from a regional economic activity perspective. The first natural experiment was provided by the assholes on the Supreme Court that said the Medicaid expansion deal was too good of a deal for states to pass up and therefore it was coercive and therefore it had to be voluntary without penalty. This is producing the natural experiment of Expansion states and non-Expansion states. Unsurprisingly states that expanded Medicaid are seeing uninsured rates drop dramatically as well as more robust local economy as they are now receiving an “export” cash flow of .5 to 1% of gross state product from the federal government. That will spin out to four or five local jobs in “secondary” industries from each job in healthcare that is being created or sustained by Medicaid expansion. Non-expansion states are seeing cash outflows in increased taxes or lower Medicare Advantage payment rates without any corresponding cash inflow. Their hospitals are still seeing high numbers of uninsured patients as other compensating funds have been cut. They are in trouble.
The second natural experiment is the ongoing differentiation in degrees of Exchange acceptance and resistance. Kentucky and West Virginia are states that don’t like Obamacare but they sure as hell like the Kynect Exchange or the Exchange website. There was political support to engage in massive outreach and get people health insurance even if certain names had to be elided to get people to sign up. On the other hand, Georgia engaged in massive resistance to navigator training and Florida attempted to keep outreach efforts from using any government (state or local) building. States with high Exchange penetration rates should see more money returned to their states in the form of subsidies than states that actively obstructed.
Finally, if Halbig is upheld by the Supreme Assholes, we’ll quickly see half the states that would be screwed do the Gaba two-step of buying a new web domain name to use as a splash page and then getting the summer IT intern redirecting visitors from that splashpage to Healthcare.gov. These states would see no change, while the Confederacy and Great Plains Republican base states would take multi-billion dollar hits in order to save $200 for a domain and a redirect.
Again, we’ll get a nice real world validation of import-export economic development modeling thanks to assholes on the Supreme Court and bullshit peddlers like Addler and Cannon.