I’m clearly not above wonking out every now and again. And it’s worth looking at the facts on the costs of the Medicaid expansion. But before we go that far, you have to understand how this is not about costs to those who want to deprive their poorest citizens health care, and it should be about costs to those of us who want to extend it. It’s about lives. And it’s also, it must be said, about 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) [...]
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.
This is absolutely right, and why you must fight an allegedly moral case (about fairness) with the moral case about our responsibility to our fellow man, particularly throwing the consequences of rejection – mass death – in the faces of these pro-lifers.
So yes, I’ll go through the motions of assessing the costs to states, because I actually think the wonks are being hacks in shaping the argument. But I’d rather see more appeals to emotion than reason on this one. Because there are no rationalists on the other side to which to appeal.
Anyway, as it stands today, 16% of all state general fund budgets go to Medicaid. It has increased over the last several years, but only moderately, because Medicaid keeps costs down. If all states expanded their Medicaid programs under the ACA, the Congressional Budget Office estimates it would cost them $73 billion between now and 2022, and that’s only 2.8% of total Medicaid costs over that period. However, this does not cover total costs to the states.
First of all, they would have to account for increased IT and personnel costs to ramp up the expansion. The states pick up those administrative costs. Second, if the publicity surrounding the Medicaid expansion leads people who would have been covered under the old state policy to sign up, that costs the state at the old funding level. They don’t get a 90% match for a previously eligible recipient. They get the old 57% match (these are averages, the numbers vary from state to state).
Most important, state governments have been conditioned not to expect federal participation to remain stable over time. They expect changes, and with budgets the way they are the possibility exists for cost-shifting. This is how wonks will lose the wonk argument with conservatives. They will claim that the expansion “puts states on the hook” for potential future costs.
Does this outweigh the existing costs of uncompensated care, indigent care and other programs, which states already pick up? No. It may be the case that states would SAVE money by opting into the Medicaid expansion, especially those states who are currently stingy with their programs. In other words, conservative-leaning states, which stand to benefit more because the government will pick up more of their Medicaid program than a state that was previously more generous.
But that’s arguing with 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.
So Kevin Drum, I’ll take your bet, especially if Democrats continue to rely on easily muddied wonkish arguments and the largesse of the hospital industry to force the Medicaid expansion through. The way I see it, I win either way. Either I win a bet I don’t want to win, or my criticisms spur some actual political combat on this issue, 45-plus states get covered, and the nation wins.