All the Dem operatives and commentators ensuring that every state will “eventually” (an indeterminate length) opt into the Medicaid expansion makes the case that they will see what a good deal it is for the states and simply have to comply. Greg Sargent looks at some numbers from the Urban Institute showing that states would spend $90 billion less on health care from 2014-2019 under the Affordable Care Act. This is because of the savings from uncompensated care and certain Medcaid eligibles rolling into programs with higher levels of federal support. In some states, they will actually save money from carrying out the full law, including opting into the expansion.
* Wisconsin could save as much as $3.7 billion from 2014-2019
* Iowa could save as much as $1.9 billion from 2014-2019
* South Carolina could save as much as $678 million from 2014-2019
* Indiana could save as much as $1.7 billion from 2014 to 2019
* Nevada could save as much as $443 million from 2014-2019
These numbers are based on the total law, and don’t isolate the Medicaid expansion. We’re waiting on those numbers. But they also don’t take into account what we learned this morning, that states could reduce their Medicaid eligibility rolls and cost-shift to beneficiaries after 2014 without consequences. This is a much easier way for them to save money to their bottom lines. It exacerbates the uncompensated care problem, but hospitals will bear more of that cost.
This is a bipartisan problem, by the way. In addition to the fourteen or more Republican governors leaning toward opposition or explicitly opposed, Steve Kornacki points out that seven Democratic governors are undecided on the Medicaid expansion, and one of them, Missouri’s Jay Nixon, has said that he’s leaning against it.
Take Missouri’s Jay Nixon, the one who’s leaning against. Nixon is a first governor of a red state, one that John McCain managed to (barely) carry against the national Democratic tide of 2008. Presumably, Obama will fare worse in the Show Me State this fall, and Nixon will be seeking reelection on the Democratic ticket with him. So Nixon really has no incentive to embrace the expansion now. In the wake of the Supreme Court’s ruling, the politics of healthcare are raw, especially in a more conservative state like Missouri. Republicans are looking for ways to tie Nixon to the president and his signature law, so why make it easy for them – especially since Medicaid expansion isn’t slated to begin for a few years? It’s a hunch, but chances are a reelected Gov. Nixon would be more enthusiastic about participating than candidate Nixon appears to be.
Most of the undecided Democratic governors also hail from red states. One of them, West Virginia’s Earl Ray Tomblin, will also face the voters this fall and is one of the Democrats to announce recently that he won’t attend his party’s national convention this summer. The same calculation behind that move – Don’t get too close to Obama! – is probably a factor here too. Kentucky’s Steve Beshear, whose state voted for McCain by 16 points in 2008, won’t be up for reelection until 2015 but also has an obvious incentive to keep distance from the president. So does Colorado’s John Hickenlooper, who governors a more Democratic-friendly state, but one that could plausibly flip to the GOP when he seeks reelection in 2014.
In at least Missouri’s case, the state legislature is Republican, and their leaders have vowed to opt out. Legislatures have a say in this as well, as they would need to vote for expansion affirmatively in most cases.
Maybe that does reflect pure election-year politics on the part of these Democratic governors. But there’s always an election around the corner. And it hits at the central point, that covering poor people with health insurance isn’t currently as popular as it should be. The moral case for coverage has not been made. That brings it into a discussion of costs. And Democrats are on shaky ground in that discussion, regardless of the facts.