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for aging. Highlighting the field’s orphan status, a decade-long ini- tiative by the Substance Abuse and Mental Health Services Adminis- tration implementing evidence- based geriatric mental health and substance-abuse programs throughout the country was re- cently eliminated, just as the wave of Baby Boomers turning 65 began to crest.1 On the re- search front, National Institutes of Health policy has inexplicably allowed the systematic exclusion of study participants over 65 years of age in federally funded research involving adults (but re- quires detailed justification for research that excludes women, minority groups, and children). This policy forces clinicians to extrapolate from findings on the safety and effectiveness of treat- ments that have been tested only in younger adults, and it perpetu- ates what has been called the “ev- idence-free” practice of geriatrics.

We believe that steps should be taken to mandate the inclusion of older adults in federally funded research unless there is scientific justification for excluding them, and we agree with the IOM that immediate steps are needed to re-

store the national program sup- porting the implementation of geriatric community mental health and substance-use programs. Emerging Medicare accountable care organizations should inte- grate geriatric mental health and substance-use expertise as com- ponents of health coaching and chronic disease management for patients with complex, high-cost health conditions. The potential for prevention must also be tapped, in part through the adop- tion of evidence-based psycholog- ical interventions that reduce the incidence of depression among patients with health conditions associated with greater risk, such as stroke and macular degenera- tion. Finally, the fragmentation and neglect of services and research may be addressed by creating a dedicated federal office responsi- ble for overseeing funding and coordination across the different agencies responsible for aging, mental health, and substance-use disorders.

Although these reforms are necessary first steps, they will be insufficient without dramatic changes in what we do and how we do it. If we recognize that

mental health care is a core com- ponent of general health care for aging Americans and transform the health care workforce ac- cordingly, there may be hope that we can weather the approaching “silver tsunami.”

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From the Departments of Psychiatry and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Ha- nover, NH (S.J.B.); and the Dartmouth In- stitute for Health Policy and Clinical Prac- tice, Lebanon, NH (S.J.B., J.A.N.).

This article was published on January 23, 2013, and updated on February 7, 2013, at NEJM.org.

1. Institute of Medicine. The mental health and substance use workforce for older adults: in whose hands? Washington, DC: National Academies Press, 2012. 2. Bartels SJ, Clark RE, Peacock WJ, Dums AR, Pratt SI. Medicare and Medicaid costs for schizophrenia patients by age cohort compared with costs for depression, demen- tia, and medically ill patients. Am J Geriatr Psychiatry 2003;11:648-57. 3. Diachun LL, Charise A, Lingard L. Old news: why the 90-year crisis in medical elder care? J Am Geriatr Soc 2012;60:1357-60. 4. Reynolds CF III, Albert SM. Management of mental disorders: lessons from India. Lan- cet 2010;376:2045-6. 5. Patel V, Araya R, Chatterjee S, et al. Treat- ment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007;370:991-1005. DOI: 10.1056/NEJMp1211456 Copyright © 2013 Massachusetts Medical Society.

Underside of the Silver Tsunami

U.S. Governors and the Medicaid Expansion — No Quick Resolution in Sight Benjamin D. Sommers, M.D., Ph.D., and Arnold M. Epstein, M.D.

With President Barack Obama’s reelection in No- vember, the Affordable Care Act (ACA) will remain the law of the land for the foreseeable future. But since the Supreme Court rul- ing on the ACA, states have been grappling with the option the Court presented — whether to participate in the expansion of

Medicaid eligibility to all adults with family incomes at or below 138% of the federal poverty level. In the aftermath of the 2012 election, it is uncertain how this process will play out, but what the states decide will play a criti- cal role in the future of the U.S. health care system.

We undertook an in-depth ex-

ploration of the views expressed by governors about the ACA Med- icaid expansion from the time of the Supreme Court ruling in June through 1 month after the November election. Although gov- ernors are, of course, only part of the state-level policymaking process, they directly oversee each state’s Medicaid program

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in the executive branch and of- ten set the terms of debate with the legislature. We collected pub- lic statements (for full methods and references, see the Supple- mentary Appendix, available with the full text of this article at

NEJM.org)1,2 from documents published in the summer and fall of 2012. In five states with newly elected governors, we in- cluded campaign statements from the winning candidate. We iden- tified major themes voiced by

governors and cross-tabulated them according to whether each governor supports the expan- sion, opposes it, or remains un- decided (see Table 1). We then identified any changes since the election.

Table 1. Likelihood of U.S. Governors’ Support for Expanding Medicaid under the ACA.*

State (Governor’s Party)

View on Medicaid Expansion

State (Governor’s Party)

View on Medicaid Expansion

Before Election

After Election†

Before Election

After Election†

Florida (R) Oppose Undecided Alabama (R) Undecided Oppose

Georgia (R) Oppose Oppose Alaska (R) Undecided Undecided

Iowa (R) Oppose Undecided Arizona (R) Undecided Undecided

Louisiana (R) Oppose Oppose Colorado (D) Undecided Support

Maine (R) Oppose Oppose Idaho (R) Undecided Undecided

Mississippi (R) Oppose Oppose Indiana (R)§ Undecided Oppose

Nebraska (R) Oppose Oppose Kansas (R) Undecided Undecided

South Carolina (R) Oppose Oppose Kentucky (D) Undecided Undecided

Texas (R) Oppose Oppose Michigan (R) Undecided Undecided

Virginia (R) Oppose Oppose Missouri (D) Undecided Support

Arkansas (D) Support Support Montana (D)§ Undecided Support

California (D) Support Support Nevada (R) Undecided Support

Connecticut (D) Support Support New Hampshire (D)§ Undecided Support

Delaware (D) Support Support New Jersey (R) Undecided Undecided

District of Columbia (D)‡ Support Support New Mexico (R) Undecided Support

Hawaii (D) Support Support North Carolina (R)§ Undecided Undecided

Illinois (D) Support Support North Dakota (R) Undecided Undecided

Maryland (D) Support Support Ohio (R) Undecided Undecided

Massachusetts (D) Support Support Oklahoma (R) Undecided Oppose

Minnesota (D) Support Support Pennsylvania (R) Undecided Undecided

New York (D) Support Support South Dakota (R) Undecided Oppose

Oregon (D) Support Support Tennessee (R) Undecided Undecided

Rhode Island (I) Support Support Utah (R) Undecided Undecided

Vermont (D) Support Support West Virginia (D) Undecided Undecided

Washington (D)§ Support Support Wisconsin (R) Undecided Undecided

Wyoming (R) Undecided Oppose

* ACA denotes Affordable Care Act, D Democrat, I Independent, and R Republican. † “After election” refers to views as of January 13, 2013. In states with newly elected governors, “before election” refers to the

views of the outgoing governor, and “after election” refers to the views of the governor-elect. ‡ The mayor is the head of the government of the District of Columbia. In our analysis, we therefore treated the mayor of the

District of Columbia as the figure comparable to the governors in the 50 states. § In these states, a new governor was elected in November 2012.

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Table 2 shows the most com- mon themes, according to gov- ernors’ support for or opposi- tion to the Medicaid expansion. Among governors opposed to expanding Medicaid, statements about affordability and impact on state budgets were nearly universal (92%). Cost concerns fell into several categories. Some pointed to the so-called wood- work effect, in which the ACA could draw previously eligible but unenrolled persons into Medicaid, at greater cost to the

state. More than half the gover- nors opposing expansion pre- dicted that the federal govern- ment would renege on the generous terms of the ACA and scale back its share of Medicaid spending. Newly elected Gover- nor Mike Pence (R-IN) compared the expansion to “the classic gift of a baby elephant. . . . The federal government says, ‘We’ll pay for all the hay — for the first few years.’”

Beyond cost, governors ex- pressed concern about the lack

of state f lexibility or their belief that Medicaid may foster depen- dence among beneficiaries. For instance, Dennis Daugaard (R-SD) declared that “able-bodied adults should be self-reliant” — in con- trast to children or people with disabilities, the traditional Med- icaid beneficiaries. Others argued that Medicaid itself is the prob- lem, calling it a “broken pro- gram” that provides poor care. Most vividly, Rick Perry (R-TX) said that adding uninsured Tex- ans to Medicaid is “not unlike adding a thousand people to the Titanic.”

Governors supporting the ex- pansion focused on the desire to expand coverage to uninsured persons, arguing that insurance would lead to greater access to care and improved health. Jay Nixon (D-MO) explained, “This will improve the health and the quality of life for hundreds of thousands of Missourians.” Many governors who support the Med- icaid expansion argued that it builds on previous coverage ex- pansions in their states and that it would actually save their states money by replacing local dollars with federal funds. Peter Shumlin (D-VT) explained that opponents “are acting like we are not already paying for this. What we’re proposing . . . is to pay less for something that we are already paying for right now.”

Among uncommitted gover- nors, there were three dominant themes. First, three quarters of these governors said they need- ed more information on federal requirements, cost and enroll- ment projections, and policy al- ternatives. Second, affordability was a key concern, including the possibility of decreased federal funding in the future; as Jan

U.S. GovernorS and The Medicaid expanSion

Table 2. Common Themes in Governors’ Statements on Expanding Medicaid, Stratified by Support for or Opposition to the Expansion.*

Group and Theme No. of

Governors (%)

13 Governors opposing Medicaid expansion

Concerns about impact on state budget 12 (92)

States need more flexibility, freedom from federal oversight 9 (69)

Federal government will renege on funding 7 (54)

States would have to raise taxes to pay for it 7 (54)

Uncertainty, need more information 7 (54)

Medicaid is a “broken program,” harms its beneficiaries 5 (38)

Entitlement programs create dependency 4 (31)

18 Governors supporting Medicaid expansion

Medicaid will help cover the uninsured 14 (78)

Expansion bolsters state’s preexisting efforts in health care 11 (61)

Will save state or taxpayers money 7 (39)

Medicaid will improve people’s health 4 (22)

20 Undecided governors

Uncertainty, need more information 15 (75)

Concerns about impact on state budget 11 (55)

States need more flexibility, freedom from federal oversight 9 (45)

Worried about having to cut funding for education and other programs

6 (30)

Waiting until after election to make decision 6 (30)

* Data are based on an analysis of 253 articles published between June 28 and December 7, 2012. Support for or opposition to the Medicaid expansion was deter- mined on the basis of the most recent comments made by governors, their admin- istrations, or both. Since the time of this analysis, 3 additional governors announced their support for the expansion in early January, bringing the revised total to 21 gov- ernors in support and 17 undecided. See the Supplementary Appendix for details on methods and a full reference list.

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Brewer (R-AZ) explained, “At any whim they could just pull the money. So yeah, I’m a little gun- shy.” Finally, early on, nearly one third of undecided governors said they were waiting until the elec- tion to evaluate their options.

Although some may have ex- pected the uncertainty to resolve swiftly after the election, that has not happened: as of January 2013, a total of 15 of the 26 governors who were undecided before the election remained un- decided (see Table 1). Some of this uncertainty reflects ongo- ing efforts to gather information about what will be permissible under the law. Several governors petitioned Medicaid to permit partial expansions, such as in- cluding only people with in- comes of up to 100% of the fed- eral poverty level. They reasoned that the federal government would pay the full cost of tax credits for people with incomes between 100 and 138% of the poverty level who sought health insurance through an exchange, whereas under the Medicaid ex- pansion, states will have to pay 10% of the costs in the long run. However, the Department of Health and Human Services re- cently clarified that partial expan- sions would not be permitted.3

Some ACA supporters con- tended that governors’ opposition after the Supreme Court ruling was simply preelection political posturing and that most states would find the ACA’s generous federal funding impossible to refuse.4 Some of the movement since the election bolsters this perspective: six governors have newly announced their support, including the first two Republi- can governors to publicly en-

dorse the expansion. Two other governors who previously op- posed the expansion have now indicated that their minds are not completely made up. Rick Scott (R-FL), previously one of the most vocal opponents of the law, explained, “The election is over, and President Obama won. I’m responsible for the families of Florida. . . . If I can get to yes, I want to get to yes.”

However, not everyone chang- ing position has endorsed ex- panding Medicaid. Five previously undecided Republican governors are now opposed, and some governors say they won’t decide until 2015 or 2016. Some oppo- sition may remain a negotiating ploy by governors with respect to opposing lawmakers or the federal government, but predic- tions of a rapid, pro-expansion resolution were apparently mis- taken. Moreover, governors are only part of the story; several statehouses (including the Re- publican-led Missouri legisla- ture and the newly Democratic Maine legislature) plan to op- pose their governors’ positions on the expansion.

Overall, these results demon- strate governors’ conflicting views about the value of expand- ing insurance coverage versus the costs and federal oversight involved in doing so through Medicaid. As the dust has set- tled after the elections, no clear consensus has emerged, with 17 states still undecided and well under half supporting Medicaid expansion. It now appears that the ACA’s 2014 coverage expan- sion will have large unintended gaps, as low-income adults in at least a dozen states remain in- eligible for any kind of public

subsidy for health insurance. Al- though those with incomes above 100% of the federal pov- erty level will be eligible for tax credits for exchange coverage in states that decline to expand Medicaid, that will still leave millions of adults living below the poverty level without health insurance and without the means of acquiring it.

Though Medicaid was initially enacted in 1965, nine states did not participate until 1970 or lat- er, and it took nearly 20 years before the last holdout joined.5 One can only speculate about whether that history is about to be repeated, with insurance cov- erage for millions and the fate of the ACA hanging in the balance.

Disclosure forms provided by the au- thors are available with the full text of this article at NEJM.org.

From the Department of Health Policy and Management, Harvard School of Public Health, Boston.

This article was published on January 16, 2013, at NEJM.org.

1. Where each state stands on ACA’s Medic- aid expansion. Washington, DC: Advisory Board Company, 2012 (http://www.advisory .com/Daily-Briefing/2012/11/09/ MedicaidMap). 2. Across the USA. McLean, VA: USA Today, 2012 (http://usatoday30.usatoday.com/news/ usaedition/2012-07-13-states13box_ st_u.htm). 3. Frequently asked questions on exchanges, market reforms, and Medicaid. Baltimore: Centers for Medicare & Medicaid Services, December 10, 2012 (http://cciio.cms.gov/ resources/files/exchanges-faqs-12-10-2012 .pdf). 4. Medicaid expansion may turn out to be an offer states can’t refuse. Mother Jones. July 18, 2012 (http://www.motherjones.com/ kevin-drum/2012/07/medicaid-expansion- may-turn-out-be-offer-states-cant-refuse). 5. A historical review of how states have re- sponded to the availability of federal funds for health coverage. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2012 (http://www.kff.org/medicaid/ upload/8349.pdf). DOI: 10.1056/NEJMp1215785 Copyright © 2013 Massachusetts Medical Society.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.