INVITED COMMENTARY 48 NCMJ vol. 78, no. 1 ncmedicaljournal.com This commentary argues against Medicaid expansion in North Carolina for 5 reasons: Expansion will reduce access to care for highly vulnerable individuals who are already enrolled in Medicaid; it is unlikely to save lives; it is unafford- able in the long run; its current financing structure encour- ages fiscal irresponsibility; and it will eliminate more jobs than it creates. T here are at least a dozen good reasons for states not to expand Medicaid under the Patient Protection and Affordable Care Act (ACA) [1]. However, I will limit myself to a discussion of the 5 most compelling reasons why North Carolina should remain among the 19 states that have not adopted this expansion. Medicaid Expansion Will Reduce Access for Existing Medicaid Recipients Medicaid is among the worst forms of health insurance offered in our state. Despite the comprehensiveness of Medicaid coverage, many Medicaid beneficiaries have great difficulty in locating a provider. Before the ACA was enacted, 31% of doctors nationally refused to accept new Medicaid patients, compared to only 17% refusing new Medicare patients and 18% refusing new patients with private insurance [2]. There are many reasons for this refusal to accept Medicaid patients, but a principal driver is low reimbursement rates [3]. While Medicaid reimbursement is lower than payments for other types of insurance, North Carolina actually pays physicians higher Medicaid fees than some other states. North Carolina’s physician fees under Medicaid are only 21% lower than Medicare fees, compared to 34% lower nation- ally [4]. This has resulted in a higher Medicaid provider participation rate in North Carolina than in other states, but access problems remain, with the average Medicaid caseload per physician in North Carolina being about 30% higher than the national average [5]. As this high caseload illustrates, the ACA is being imple- mented during a period when we are already facing a phy- sician shortage. Further, a model developed by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill showed that, in the year 2020 alone, Medicaid expansion would increase the unmet demand for physician services by over 25% [6]. In the context of this physician shortage, it makes little sense on ethical or clinical grounds to divert care away from existing Medicaid beneficiaries, who are among our most vulnerable populations—elderly individuals, persons with disabilities, pregnant women, infants, and children. This is especially true given that the lion’s share of the expansion population consists of nonelderly able-bodied adults. It also seems unwise to make promises to newly eligible Medicaid benefi- ciaries on which we will be hard-put to deliver. Medicaid Expansion Is Unlikely to Save Lives One proponent of Medicaid expansion criticized the deci- sion not to expand Medicaid by saying, “a thousand or more [North Carolinians] die each year as a result of one of the most cruel and indefensible decisions in N.C. history” [7]. However, there is no good evidence to support this hyper- bole regarding the impact of health insurance on mortality risk. Indeed, it is worth taking the time to understand the origins of this misleading claim. There is very mixed literature showing (possibly) that having private insurance lowers mortality risk relative to remaining uninsured [8]. These studies are inherently prob- lematic in that they are observational studies rather than randomized controlled trials. Consequently, no matter how many sophisticated statistical adjustments we make, we can never entirely rule out the possibility that observed differ- ences in the rate of death between insured people versus their uninsured “statistical twins” are due to unmeasured differences between the 2 groups rather than to their insur- ance status. Uninsured people, for example, may be more willing to make risky life choices that are not captured in the observed data (eg, driving without seatbelts or driving drunk), and it may be that these choices, rather than their lack of insurance, result in objectively higher death rates compared to the death rate of their insured counterparts. Even if the studies were flawless, there are 2 reasons why it is inappropriate to use this literature to extrapolate The Case Against Medicaid Expansion in North Carolina Christopher J. Conover Electronically published January 23, 2017. Address correspondence to Dr. Christopher J. Conover, Duke University, Box 90392, Durham, NC 27705 (conoverc@duke.edu). N C Med J. 2017;78(1):48-50. ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved. 0029-2559/2017/78114