Okay, you’re saying, you’re right about Republican governors opting out of the Medicaid expansion, Dave, and liberal establishment types are acting completely blind to the threat. But what do you suggest they do about it? After all, if Republican governors value their positions, they’ll fall in line with the prevailing opinion of their hardcore base, which clearly falls on the side of rejecting government-run health care and opting out. So what are the options here?
I’d preface it by saying there aren’t many. I don’t believe in the Green Lantern Theory that hospital lobbyists can just force their will on the political establishment in conservative-leaning states and push the expansion into reality. I don’t think there’s any hope in moving some of these governors. And still, I think there are ways to handle this beyond blithely sitting back and hoping for the best.
• Make the moral argument: Appeals to the Medicaid expansion being a “great deal” for states will fall flat. Conservatives won’t trust the source, and will shift the numbers in their favor. Plus there really are costs to expansion on the states, even if they’re minimal.
What cannot be elided is the idea that we have a responsibility to each other, and don’t want to see the day when our brothers and sisters die in the street for lack of medical care. I don’t expect this to reach the outer edges of the tea party right, but it should be able to sway moderates. Since 2008, the moral argument is the argument that has not really been employed. It was dropped in favor of arguments about “bending the cost curve.” But the idea that health care is an essential right and not a privilege has the ability to move people from where they are.
Conservatives and Republicans do not concede the moral imperative of universal health care — although that leaves them isolated in the entire advanced democratic world. There is no other country among our allies in Western Europe, Canada, Japan, and Australia that does not stipulate every citizen will have health insurance from birth as a matter of course. In all those countries, the center-right parties have long accepted the moral imperative, whatever initial misgivings they may once have voiced. So do the medical- industrial complexes of every nation but ours [...]
So the moral issue must be joined in the most aggressive fashion possible. Not so much by showing empathy for the uninsured—liberals are always wonderful at showing empathy. No, by belligerently challenging conservative pundits and Republican politicians at every opportunity, reminding them how lucky they are to have health care themselves.
This is especially true in the case of Medicaid, which hits a vulnerable and often invisible population. Over the years-long battle for expansion, it is incumbent to make them visible and real and unforgettable. That’s a far better campaign to “I can’t believe what a good deal these people are passing up!”
• Find allies: Chuck Grassley discovered the last vestiges of his soul in a speech last week:
With this decision, states now have the option to expand Medicaid to cover people below poverty. Mr. President, the states had that option before the Affordable Care Act was passed. So what does this decision mean in real terms?
It will be up to the states to determine if they will cover the poorest of the poor. The federal government cannot guarantee coverage. So now people with jobs will have to purchase insurance under the tax mandate. People without an income, people who are below poverty are dependent upon the state in which they reside.
Now, Chuck Grassley’s own governor, who he supported in Iowa, is one of the many saying they will reject the Medicaid expansion. Shouldn’t he be confronted with that? Shouldn’t he be encouraged to make the moral argument or suffer the same tarring as his colleagues, who are unperturbed by the suffering of those poorest of the poor?
And those allies could be put to use….
• Find real solutions. The solution to all this, the one that would actually be the most cost-effective for the states in addition to the one with the most moral force, is to federalize Medicaid. Republican Senator Lamar Alexander made the argument six weeks ago:
When I was governor and we were allotting state tax money for roads, schools, state agencies and the like, we’d have to choose between spending on Medicaid or public higher education. When states are forced to spend more of their limited tax dollars on Medicaid, that usually means they spend less on education.
Last year in Tennessee, Medicaid funding was up 16% while state support for higher education was down 15%. As a result, tuition and fees at public four-year universities rose more than 7% [...]
Then there’s the Grand Swap’s potential for strengthening Medicaid: A single manager, even if it is the federal government, would operate Medicaid more efficiently because it would be forced to implement the mandates it crafts.
Alexander wanted to make the “Grand Swap” between Medicaid and education funding, pushing K-12 funding to the states while pushing Medicaid to the federal government. I think that needs to be the right pole for the discussion. But it’s true that Medicaid would work much more efficiently at the federal level, with more bargaining power and more maintenance of effort across regions. No longer would the poor be dependent on the whims of their state governor for whether they get coverage. We would have a coherent national health policy for that class of Americans.
Republicans would oppose this, you say. But Republicans know they’re not repealing the health care law. And a federalization of Medicaid could be swapped into a larger process…
• Time to horse trade. We have this big fiscal slope coming up. We have huge questions about federal spending and tax policy. Why shouldn’t Medicaid, this huge burden on state government, be entered into that discussion? The House Republican budget already does that in a bad fashion. There’s no reason why Democrats in Congress shouldn’t be working on a solution to this huge problem, where 25-30% of the coverage expansion in the ACA gets squandered because of conservative governors. I don’t know what a deal looks like, but federalization of Medicaid should become another bargaining item for the Dems.
Again, I don’t believe that some of this can be stopped in the near term. But hoping it works out “eventually” (the new favorite word for commentators on this) is not a plan. And thousands will die in that time period while waiting for full adoption. That should bring a sense of urgency to this topic, not complacency.