I keep seeing these confident predictions from health care experts that no state would be so foolish as to reject the Medicaid expansion for their state. I want to set up a poker game with these people, to provide for my family in retirement. How many times can you say “well that’s so radical and extreme, it could never happen!” and be wrong before you review your assumptions?
The idea that you can just point to a set of numbers and say “but it’s almost all paid for by the federal government!” and convince ideologically motivated conservatives with that reasoning is really rich. The consensus opinion on the right is that giving free services to poor people puts them on the road to serfdom and crushes their innovative spirits and shackles them rather than allowing them to grow and succeed. Really they don’t want rich people to pay for “others” to get free stuff.
But I don’t even think the wonks have formulated the question properly, given that they are formulating it as wonks, rather than as partisan hacks.
Take Ezra’s formulation of the argument with regards to South Carolina, which has already announced it won’t expand Medicaid.
Take South Carolina. “We’re not going to shove more South Carolinians into a broken system that further ties our hands when we know the best way to find South Carolina solutions for South Carolina health problems is through the flexibility that block grants provide,” said Rob Godfrey, spokesman for Gov. Nikki Haley.
So how are those South Carolina solutions working out? Nineteen percent of the state’s residents are uninsured, which is well above the national average. When the Kaiser Family Foundation ran the numbers, they found the Medicaid expansion in the new law would cut South Carolina’s uninsurance rate among eligible adults by 56.4 percent. That’s the fourth-largest drop of any state in the nation. The cost of that for the federal government between 2014 and 2019? Almost $11 billion. For South Carolina? Less than $500 million.
In the short term, a rising Republican star like Haley might have reason to reject that deal. The Republican base hates the law, and so one way to build a national profile right now is to be the most implacable, unreasonable opponent of the Affordable Care Act.
But that won’t last forever. And governors also have to answer to non-Republican voters who don’t want their state missing out on billions in federal dollars, and to the hospitals in their state who have to treat uninsured patients that end up in their emergency rooms, and the insured voters who end up paying for their uninsured brethren.
What remains unspoken in these arguments (though DDay has addressed it)–even in the assessments of why these Red States already have such low rates of Medicaid coverage to begin with–is race.
Medicaid expansion in Red States is not going to be argued as “extending health insurance to uninsured adults,” but rather, “giving free stuff to people of color” (though that won’t be the phrase used).
Enlargement of Medicaid is the single most important provision of the Affordable Care Act for people of color. It’s the way that almost all non-whites covered by the law would receive insurance.
If implemented as written, the law expected to cover 32 million Americans, accounting for 80 percent of those currently uninsured. Half of the 32 million are to be brought into the system through Medicaid, and three out of four of those individuals are people of color.
Blacks and Latinos are enrolled in Medicaid at twice the rate of whites. Half of those in the program are children. As the Kaiser Family Foundation has bluntly concluded, “Medicaid enables Black and Hispanic Americans to access health care.”
Already, my anecdotal experience is that a proportion of voters in the states in question claim that the first black President has spent his first term making sure that people of color get more than their fair share of benefits (I think they make this argument based on expanded food stamp usage, though of course the argument is not coherent). The GOP frame for the Medicaid argument will not focus at all on insuring the uninsured. It will not breathe a word of how insured people subsidize uninsured people who use emergency rooms for care. Rather, it will extend and enlarge on this argument about a black President giving free stuff to black people (or Latinos in states like Texas). And I believe that will remain true even if Obama loses in November.
How could radical Republican governors not love engaging in that fight? It’s a damn good way to keep working class whites in the GOP party. It’s a damn good way to keep the base enthused. It’s a damn good way to distract from larger economic failures. It’s the same logic, of course, that has already led some of these firebreathers to embrace “Papers Please” laws that lose their states a lot of money.
Moreover, these same governors are already hard at work shrinking the number of people of color who will be able to cast their legal votes. Thus, the idea that these governors will have to respond non-Republican votes is weak, given that this fight will be accompanied by an effort to limit the number of non-Republican voters who can vote at all.
Finally, while I don’t think the TeaParty arose primarily out of racist resentment, I do think it has fed on it in the last three years. Given that fact, the likelihood its fight against Medicaid would get racist and ugly quickly is quite high.
Sure, maybe it will in fact play out that the powerful hospital lobby will ensure even the Red States embrace Medicaid expansion. Maybe that leverage will be enough to achieve the no-brainer policy goals with little Democratic engagement.
But consider the price that outsourcing this fight to the hospitals will have in the interim. It would mean Democrats would not respond to race-based attacks with important arguments about the well-being of the nation as a whole, with important education about how the expansion of Medicaid is a key part of bring healthcare costs down more generally.
I believe, like DDay, the risk that states will forgo Medicaid is already too great. But even if we win that battle, what battles will we would lose along the way if we don’t fight this one aggressively.