A central feature of the Affordable Care Act is the expansion of Medicaid. It has been a source of intense debate and controversy since the Supreme Court ruled unconstitutional the penalty that was to be imposed on states refusing to accept its expansion.
Within the past month, two major new studies have appeared, adding urgency to the issue. In one, researchers at Harvard found that a previous expansion of Medicaid in some states was associated with substantial improvements in health in general, and reductions in mortality in particular. In a second, investigators estimated that roughly 26,000 working age adults died prematurely last year in the United States because they lacked health insurance.
Individual studies, including these, have their limitations. But according to the highly respected health economics specialist Aaron Carroll, the accumulated evidence is clear: Medicaid is good for people and Medicaid expansion will save lives.
In spite of these facts, a handful of Republican governors have refused to participate in Medicaid expansion, including Rick Perry of Texas, Nikki Haley of South Carolina and Rick Scott of Florida. All have proffered some version of the same argument: Expansion represents an intolerable new burden on already-strained state budgets. One governor called it an "unfunded mandate," despite the fact that Medicaid expansion is, not to put too fine a point on it, funded.
I have written previously that Republican bleating about deficits cannot be taken seriously, given the party's now decades-long disregard for, and blatant hypocrisy about, such probity. But it's especially instructive to consider the arguments of Scott, who has become among the most high-profile critics of the law and who very prominently paraded around major media outlets after the Supreme Court ruling to explain why he will reject Medicaid expansion.
Scott offered a variation on three arguments. First, he said, Florida cannot afford the expansion because it will cost the state an additional $2 billion a year. This claim, as numerous fact-checkers have pointed out, is a blatant falsehood. Scott has omitted the fact that the additional costs Florida would face don't kick in for several years, since the federal government agrees to pay for 100 percent of the expansion until 2017. After that, the federal government will eventually cover 90 percent of expansion costs. By contrast, the feds pay 55 percent of Florida's Medicaid expenses under current law.
Even when Florida is on the hook for 10 percent of the expansion after 2020, the state's actual liability comes to about a quarter of Scott's figure. How does Scott arrive at $2 billion? By including hypothetical costs that the state might incur even in the absence of the law, plus other accounting shenanigans.
It's important to note that even if Scott's rejection of the Medicaid expansion saves Florida money, it only does so by passing on the costs of uncovered individuals to families and hospitals. For example, the majority of elderly people living in nursing homes are covered by Medicaid. Remove that money and families have to come up with the cash instead. Florida's bottom line might look a little better, but the costs to families and society are enormous.
Though it's not specifically germane to Medicaid expansion, during his media tour Scott lamented the law's alleged impact on small business. Scott recounted a conversation with a business owner who Scott says told him that he would go bankrupt under the new law because he couldn't afford to provide health insurance to his 20 employees. Since the law exempts businesses with fewer than 50 employees from the employer mandate, Scott's professed concern is baseless. In fact, the new health care law provides new subsidies for small businesses that choose to cover their employees. The impact of the new law on small businesses is diametrically opposed to Scott's claims.
Scott's third "argument" was a repeat of the old Shibboleth that the new law would entail "rationing," characteristic of other universal systems. This was part of his attempt to broadly disparage the Affordable Care Act by comparing it to those horrible systems in Canada and Western Europe that cover everybody, spend far less money than we do and, in general, achieve as good or better health outcomes.
The new law, of course, does not entail new "rationing" in anything like the way Scott argues. Even under full implementation, the U.S. will remain both the least socialized health care system of any wealthy country and the only one without truly universal coverage.
There is reason to believe that, in the long run, all states will opt in to the expansion of Medicaid, just as all states, over time, opted in to the original program—because it's obviously a good deal. Medicaid expansion will produce a massive increase in coverage for the vulnerable people who are the program's main beneficiaries, including children, the disabled, the poor and the elderly.
The game of extremist chicken now playing out in the GOP will ultimately, if not immediately, collide with public opinion, the opposition of powerful interests (such as hospitals and pharmaceutical companies that benefit from expansion), and the dictates of good governance and basic common decency. Meanwhile, though, the potential resistance of holdout governors will have real-world and life-and-death consequences for those states' most vulnerable citizens.
Incidentally, Mitt Romney has whole-heartedly endorsed the budget plan proposed by U.S. Rep Paul Ryan, which would eliminate all Medicaid expansion and gut much of the funding for current Medicaid. Adoption of such a plan would leave many more families unable to afford basic health care and exposed to the possibility that future medical costs might financially devastate them.
Since Jan. 20, 2009, Republicans have alleged that almost any new policy proposal, apart from tax cuts and deregulation, creates paralyzing uncertainty and economic disaster. That's rich coming from a political movement whose central premise is that risk (i.e., uncertainty) is the key motivation driving capitalist innovation and wealth creation. If uncertainty is so bad, what could be worse for a family than having to wonder whether an unpredictable medical expense might result in bankruptcy? And why is the GOP so desperate to ensure that more and more Americans find themselves precisely in that position?
One thing we do know, however, is the consequence of reduced health coverage. As Carroll, the health economics specialist, has put it, states "can focus on how much they're willing to spend to save lives, but they shouldn't deny that that's what's at stake."
This article appeared in print with the headline "An unhealthy dialogue."