When a state blocks Obamacare, ERs close: The lesson of Louisiana

Louisiana Gov. Bobby Jindal speaks during a prayer rally in Baton Rouge last month. Did the prayer agenda include asking divine help to keep a local ER open?
(Jonathan Bachman / Associated Press)
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Baton Rouge, La., is about to lose one of its crucial hospital emergency rooms, and the reason is clear: The administration of Gov. Bobby Jindal has refused to expand Medicaid under the Affordable Care Act, and won’t put up any other money to keep the facility open.

Because of the scheduled closure of the ER of Baton Rouge General Medical Center-Mid City, patients needing emergency treatment will have to travel as much as 30 minutes longer to reach the nearest ERs.

Jindal has tried to position himself as the last stalwart Republican opponent of the ACA, but his state’s experience shows that his position is folly.


The ACA was designed to encourage states to expand Medicaid--almost entirely at federal expense--as a means of cutting the uncompensated medical care hospitals had been forced to provide for low-income individuals and families. Much of that care has been customarily delivered through the ER.

In the expectation that Medicaid would pick up the slack, the ACA reduced so-called disproportionate share hospital payments, which went to hospitals serving a large number of the uninsured. So institutions in states that have refused to expand Medicaid, like Louisiana, have faced a double-whammy--they still have to serve a large number of uninsured patients, but they have less money to do so.

The ACA has reduced uncompensated care costs across the board--by $5.7 billion in fiscal 2014 compared with what they would have been otherwise, according to the Department of Health and Human Services. (See accompanying chart.)

But most of that effect is seen in Medicaid expansion states. The crisis has continued for hospitals in non-Medicaid expanding states. The problem is so acute that the Tennessee Hospital Assn. offered to pick up the state’s cost of expansion. That wasn’t enough: Conservative Republicans who dominate the state legislature on Wednesday voted in committee to kill a compromise plan by Republican Gov. Bill Haslam to expand Medicaid to cover more than 250,000 low-income uninsured adults.

In Baton Rouge, the Mid City ER, which recorded 45,000 patient visits last year, started facing a crisis in 2013, when it inherited the case load from a nearby ER that closed. According to the Baton Rouge Advocate, Mid City’s losses were projected to hit $25 million to $30 million this year. The Jindal administration stepped in with a promised infusion of $18 million, but that turned out to be a stopgap aimed at staving off an ER closure threatened last summer. Now the ER is set to close within 60 days.

Jindal, who still evidently harbors fantasies of running for president, deserves blame for the situation. As other GOP governors have seen the light on Medicaid expansion--10 have reached agreements with the federal government recently--Jindal has become ever more obstinate.


He’s been pushing his own Obamacare repeal-and-replace plan, which mostly involves eliminating the tax deduction for employer-sponsored health plans and replacing it with a deduction allowing people to buy coverage in the individual market.

Jindal has promoted his plan with a string of distortions about the ACA and the health insurance marketplace that suggest, at best, that he has no idea what he’s talking about.

He’s left even conservative opponents of Obamacare scratching their heads: Ramesh Ponnuru of National Review said it “shows how not to replace Obamacare.” Jindal’s plan, Ponnuru observed, would favor higher-income taxpayers while leaving lower-income Americans, those covered by existing exchange plans, and many of those now enrolled in employer plans, in the dust.

“The great flaw in Jindal’s plan is that it would cause millions of people to lose their coverage,” he wrote.

That would be an interesting experiment in social insurance. Unfortunately for Louisiana residents, Jindal is experimenting on them first.

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