Talking the talk on Medicaid opt-out
Douglas Holz-Eakin, who I understand used to be a sane person, has written an early rundown of Republican talking points for the Medicaid expansion refusal:
Obamacare included a provision requiring that states expand Medicaid to cover everyone up to 133 percent of the poverty line. States that refused would lose all federal funding for the state’s program. The Supreme Court ruled that this was an unconstitutional federal coercion of the states, a decision that mirrors the fiscal reality. Instead of states’ losing all Medicaid funding if they refuse to comply, the Court restricted the federal government to withholding only the federal funding for a state’s expansion. In short, the expansion is now voluntary.
The question that immediately arises is: “If this is such a good deal, why did Obamacare have to mandate it in the first place and enforce it with a draconian penalty?” Common sense suggests that if the expansion were such a good idea, then it would have been voluntary to begin with.
It goes downhill from there.
I don't suppose one has to actually make the point that the idea of expanding health care in America, even when it costs the states next to nothing, does not have a consensus. After all, we have a fair number of people who either believe that health care is paid for by the medicine fairy or that people who can't afford the overwhelming costs should just die:
Blitzer: You're a physician, Ron Paul, you're a doctor. You know something about this subject. Let me ask you this hypothetical question. A healthy 30-year-old young man has a good job, makes a good living, but decides I'm not going to spend $200 or $300 a month because I'm healthy, I don't need it. But something terrible happens, all of a sudden he needs it. Who will pay if he goes into a coma, who pays for that?
Paul: In a society that you accept welfarism and socialism, he expects the government to take care of him.
Blitzer: What do you want?
Paul: What he should do is whatever he wants to do and assume responsibility for himself. My advice to him would have a major medical policy.
Blitzer: He doesn't have that and he needs intensive care for six months. Who pays?
Paul: That's what freedom is all about, taking your own risks. This whole idea that you have to prepare and take care of everybody --
Blitzer: but congressman, are you saying that society should just let him die?
Audience:[shouts of "yeah!"]
Those are the people who are driving the political train in the red states right now.
The Democratic response to this seems to be that the hospitals will force the states to take the money because they need it. The only problem with this is that hospitals have been getting gouged for decades and haven't been successful at getting more money for Medicaid. In fact, the pie has been steadily shrinking.
Which brings us to another of Holz-Eakins points:
Advocates of the law point out that the federal government initially picks up 100 percent of the cost, and commits to 90 percent of the cost at the end of ten years. For a state, that is attractive but far from a guarantee, so it has to figure into the calculation the probability that a cash-strapped federal government will choose in the future to shift costs to the states.
I would be sympathetic to this argument --- indeed, I think it is a very real threat to the future health of the program --- except for the fact that it will be these very same people cutting the funding (yes, with the help of Democratic useful idiots.) So, you know, it is a problem. But then that was always going to be a problem when they decided to continue to have a taxpayer funded program for the poor rather than taxpayer funded program for everyone.
He goes on to say that if states opt out the Medicaid population will be eligible for the subsidies, but that's not true. Jared Bernstein explains:
[T]hose between 100-133% of poverty–who would have been covered under the Medicaid expansion–will now be eligible for the federal subsidies to buy insurance from the state exchanges, coverage which Paul VdW says “may be more costly than Medicaid.”
The problem for Doug, Sen. Coburn and other who are making this case is that there are about four times more people potentially eligible for Medicaid below 100% than between 100 and 133%. As the figure below—from some very timely Urban Institute research—reveals, there are 22.3 million uninsured poor and near-poor people who would be eligible for coverage under the Medicaid expansion. But about 80% of them—17.8 million—are below 100% of poverty and therefore not eligible for subsidies.
All the people in the left category are going to be out of luck.
And, once more, Holz-Eakin makes the diabolical argument that the overall costs will now bust the budget because that smaller number will get the more expensive subsidies. The only reason that would happen, of course, is that the Republican Governors refuse the Medicaid money and therefore put them into the subsidy pool!
And then there's the usual nonsense:
A superior option would be the flexibility to address the needs of the sub-poverty populations on a state-by-state basis in ways consistent with each state’s norms.Right. And if a state's "norms" is to let people die it would be wrong to interfere. People are different! We shouldn't inflict our values on them. Letting some Americans languish in poverty and illness and die early preventable deaths while others are allowed to have health care and security -- all on the basis of some arbitrary lines drawn up long ago --- is a perfectly respectable moral position. No biggie.
I can't tell the future. It's certainly possible that the hospitals will turn the screws on the Governors and force them to take the money. (You have to wonder why they haven't exercised this clout before as the current system has been draining them for several decades, but ...) This is one case where I hope the corporate powers that be are (accidentally) on the side of the angels. But if I had to guess, the politics of our time are such that it's perfectly realistic to imagine that a whole bunch of states will opt-out and that Democrats will stand there, shocked and paralyzed, when it turns out that they actually believe the bullshit they spew. Again.
Update: Dday makes the important point that this is not about logic:
I don’t know why, given shared history, anyone would believe that logic will rule the day, and red state governors will go against their entire ideological worldview and spend taxpayer dollars – however small – to cover poor people, in many states largely people of color. And if you rely on this numbers game, if you never make a moral argument for WHY poor people shouldn’t have to choose between food or medical care, you have a whole bunch more problems than just this Medicaid expansion.
That's right. This is the moral center of the ACA. The case must be made for these people. If it isn't and everybody keeps being smug and indifferent to the fact that millions of poor people are going to get nothing in this deal --- and especially if we are all exhorted to keep clapping because of the technocratic genius of the subsidies and the exchanges --- I think we'll know once and for all that the moral case was never the point.