It’s not like conservative-state residents will hear only one set of data and logic relative to the Medicaid expansion debate. Republicans have their own economic analysts willing to make their own cases. Douglas Holtz-Eakin, a former head of the Congressional Budget Office, has made an early case at National Review. He begins by asking, “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,” which is off, because the penalty isn’t all that draconian, but which will play well as a talking point.
Next, you have to understand that the right views the Medicaid system as broken.
Any individual who is above the poverty line is eligible for the federal subsidies in the state-based exchanges. Individual insurance is better than Medicaid, so a state has zero incentive to expand its program on the basis of this population. Individuals will simply get their insurance at the federal taxpayer’s expense (and this is expensive — as much as $3,000 more expensive per person than Medicaid). This is the budget cost that drove the drafters of Obamacare to change course and jam millions of Americans into the broken Medicaid system in the first place.
Even more striking, for those states that have already expanded coverage above the federal poverty line, Obamacare’s “maintenance of effort” requirements expire in 2014. Accordingly, a state could cut back any expansion of its Medicaid program and shift the cost to the federal taxpayer — a pure win for the state. This would include essentially every child age 19 or younger, every pregnant woman, and many adults in large states like California, New York, Illinois, Massachusetts, and more.
Individual insurance versus Medicaid shouldn’t really be the comparison here. It should be Medicaid versus no insurance. And on that score, Medicaid is light years better.
Further, the problem with foregrounding the experience of those between 100-133% of the poverty line, who are basically eligible for subsidies or Medicaid, is that this isn’t a large population. According to Urban Institute research, 80% of those newly eligible for coverage under the Medicaid expansion are below the poverty line. States could shift those between 100-133% FPL to the exchanges, but that’s just not a big universe of people.
Holtz-Eakin does get around to those below the poverty line. But he simply doubts that the federal government will pick up 90% of the costs of the Medicaid expansion over time. He highlights “the probability that a cash-strapped federal government will choose in the future to shift costs to the states.” Finally, he calls it a “federal bribe,” which is a tribal way of saying that the government wants to compel states to cover poor “other” people with your money.
I go through this to point out the counter-argument that will be made at the state level. It’s that a) Medicaid is a “broken system,” b) the poor have other options (even though most of them don’t), and c) this puts states “on the hook” for massive amounts of money. And then it’s a he said/she said argument, regardless of the veracity of these claims. There are surely plenty of studies to be mined showing that, factoring in the cost of uncompensated care, covering the uninsured at the low end would save money. But you’re talking about a public that, in substantial numbers, doesn’t even know the Supreme Court came to a decision. People are not up on the nuances of this debate, and if someone on their team says that people don’t die from prostate cancer and breast cancer anymore, they’ll tend to believe them.
As I said yesterday, logic will not rule this debate. This isn’t about facts and figures, but partisanship. The right has these talking points that sound like logic, and it’s enough to fool the media into thinking there’s a debate here. But the real debate will happen at an elemental level. Republicans will make a moral argument, one they’ve drummed into the heads of their supporters over time, about the unfairness of your tax dollars going to free health care for a population that should help themselves rather than relying on government. If Democrats respond with numbers, they lose.