By James Kwak
In my Atlantic column on Thursday, I wrote the following about the Roberts Court’s decision to allow states to opt out of Medicaid expansion without losing their existing Medicaid funding:
“What we are going to see is Republican-controlled state governments refusing to expand Medicaid out of bitter hatred toward President Obama and spite for the working poor who need access to health care.”
For those who aren’t up to speed, the deal is basically this. Medicaid is administered by states (which often outsource it to third parties), but the federal government sets certain minimum coverage requirements that states must meet in order to receive federal funding. Those requirements are pretty low, states can choose not to cover able-bodied adults without children, regardless of their income. The Affordable Care Act required states to dramatically increase their Medicaid coverage, with the federal government kicking in 90 percent of the additional funding required (100 percent in the early years).
So, you’re a Republican state governor. (Assume that your party controls the legislature.) You have some working class households in your state that make, say, $25,000 and don’t get health insurance through work. Currently many of them are uninsured. As governor, you have some obligation to look after their interests, even if it’s not a technical legal obligation. You could buy all of them health insurance (not very good health insurance, mind you, but it’s far better than nothing) at a 90 percent discount because the federal government will pick up the rest of the tab.*
On economic grounds, the decision is obvious: you expand Medicaid. And this is why various commentators have said that, when all the brouhaha dies down, most states will do it.
But the politics are equally clear. Medicaid expansion is the one part of “ObamaCare” that the Supreme Court specifically excused you from. If you expand Medicaid, in your next primary, the Tea Party candidate—buoyed by millions of dollars from Karl Rove and the Koch Brothers, who want Medicaid to be as small as possible—will say that you supported ObamaCare. And, frankly, she will be right: you supported ObamaCare because it was good for the people of your state. But you can’t say that, because that sounds even worse.
It comes down to this: whom do you care about more, the working poor or the Tea Party?
So far, conservative darlings like Scott Walker of Wisconsin and Rick Scott of Florida have been very clear where they stand. They are willing to turn down oodles of federal money on the grounds that they need to kick in ten cents on the dollar to cover people who would otherwise go without health insurance.
You really have to hate poor people a lot to make that decision.
* If you don’t cover them, you are saving the federal government money, but only a small fraction of that money will go to the citizens of your state.
The Baseline Scenario 
Too often, in the heartland, the working poor are the tea party.
It’s also stupid because opting out of the Medicaid expansion won’t even save the 10%. Florida et al will simply spend their taxpayer’s money elsewhere.
Uninsured people will keep going to expensive emergency rooms for minor ailments. Uninsured sick people will allow easily-treated and preventable conditions to grow serious. Uninsured mentally ill people will become expensive prison inmates.
Walker and Scott know this, too. They are idiotic as well as heartless.
‘As governor, you have some obligation to look after their interests, even if it’s not a technical legal obligation. ‘
Yeah, what’s a little thing like the law got to do with it.
Patrick R. Sullivan: Yeah, what’s a little thing like the law got to do with it.
So true. If all you concern yourself with is complying with the law, you only do the minimum to stay out of jail. Now there’s a motto to lead by: “We’re one step ahead of indictment.”
There is one constituency that is being overlooked which is the multi-million dollar hospitals. They are not going to take kindly to losses of income from a jackass governor and money talks.
Rick Perry made some comments earlier about Texas potentially getting out of Medicare. It was pointed out to him by people in high places how much money that would cost the Texas medical industry and not a word has been said since.
The problem is not jackass governors,it’s pachydermatous governors.
‘If all you concern yourself with is complying with the law, you only do the minimum to stay out of jail.’
Where do you suppose elected officials get their authority, if not the law. Are you a believer in divine right?
@ Professor James Kwak: So much of the “pure spite” goes to the RACIST ETHOS that engulfs, consumes, and inflames these southern politicians, with some exceptions, that ignoring same is casting one’s head into the sand.
That the GOP serves a largely racist constituency, also is apparent. It’s freaky to them that a man with African blood is serving as POTUS and living in the White House, largely built by African slaves, incidentally.
@Patrick R. Sullivan: A governor could do the minimum required by law or could do better than that. Does the latter trouble you? Because Prof. Kwak was suggesting a governor could do better than just legal compliance, and you apparently objected.
For example, the law in my state does not require our governor to give interviews, but he does. Is he out of line? Do you take issue with this?
@Bond Man – I think it goes deeper than just a “racist ethos”. It’s a bona-fide genetic disorder – something deeply awry in the chemical composition of their brain cells. They are incapable of recognizing what is imagination and free will. They think no one else has imagination and free will other than them, which is why they always end up believing that they are “gods”.
Western Civilization has devoted many “classic novels” (of fiction :-)) to the story of their affect on society. They are deeply misanthropic. Even their “religion” is misanthropic. If it isn’t a person’s race, it’s their gender. If it isn’t their gender, then it’s the other’s food choices….it will always be about something that is WRONG with the other person. There is no appeasing them. They LOVE to hate.
Look, the bottom line is that they need to be contained. “Democracy”, at its core, evolved as common sense protection against the power of hate. That’s why it took so long to bubble up as a political evolution (democracy). Because when the “King” was the one who freely taught everyone in the realm, by example, how to make their lives less miserable through honest work by actually working the hardest alongside his citizens, no one needed to imagine another type of government. But when, increasingly, the idealist’s kingdoms were besieged by wicked minorities hatching political conspiracies – FOR THE SOLE PURPOSE OF STEALING THE WEALTH – well, here we go….2012 in all its glory…
The Wrecking Crew ReThugs gotta go – one way or another….criminal hot-spotting is the perfect technique. Their ilk does not even deserve the great lengths we are going to to be “civilized” about containing their hate-fueled megalomania. As the fictional character “Joey” on the TV series “Friends” told everyone before they met his Grandmother, “…she was 17th in line to spit on Mussollini’s dead body hanging in the square…” – or something close to that since I haven’t seen the episode in a long while :-))
Krugman pointed out that some states have per capita incomes comparable to Greece. Could it be that the 10% would require a tax increase? And since conservatives don’t believe in shared responsibility, that isn’t a winning issue for them.
To echo what others have said, the Republican beasts who maliciously seek to torpedo better health care will save their states remarkably little. Indeed, it is likely they will _lose_ money. Some number of people would be covered under Medicaid expansion who otherwise are not. In the states that refuse the expansion, some percentage of that number will _still_ seek medical care by other means — perhaps through emergency room visits, a common option of last resort for those without insurance. We already know, conclusively, that a large percentage of uninsured do find care by these alternative means, with the bills ultimately making their way to taxpayers because the uninsured cannot afford to pay. It’s reasonable to suppose (numbers would have to rigorously checked to confirm the accounting assumptions I’m making) that if just 10 percent find alternative care who would have been covered under the expansion, then the state will lose.
So right-wing, petty, mean-spirited governors like Scott or Walker (or, soon, New Jersey’s Christie) aren’t just expressing their hatred and contempt for the poor, they are intent upon making the entire taxpaying population worse off in order to score political points.
Of course, these right-wingers also have the express intent to redistribute the tax burden down — entirely off the shoulders of the 1% donor friends. So the people they really care about won’t be affected. As Scalia intimated, the poor and middle class should just fend for themselves, or just not get sick, or — to quote another — “die and decrease the surplus population.”
“Politics” doesn’t adequately describe what motivates this sort of hatred. “Tribalism” is a better word.
The gop in it’s current incarnation is the 4th reich, – it is the nazi party. Fascist – (look up the word, compare gop policy, practices, and behavior and get back to me), pathologically pro oligarch, drenched in false twisted religious and partisan patriotic platitudes, ruthless, heartless, supremist, rooted in an incessant litany if patent lies, disinformation, and propaganda, delirious in the hatred of the poor, the workingman, immigrants, and anyone who is not superrich, white, fundamentalist christian, and fascist.
A pox on the gop. We have guns too biiiiaaatches!
Anyone who would refuse a 90% subsidy on a mandate to curb insurance less people, would need to have their heads checked by someone with an IQ greater than say, 60.
All of this commentary seems to overlook the fact that the states are in no better fiscal shape than the federal government, and some are in even worse straits. It comes as no surprise that some Governors are looking down the road and wondering where the 10 percent will come from. Based on past experience, my guess is higher property taxes, higher sales taxes, higher state taxes and even more cuts in education…
The underlying problem is cost! Healthcare is not accessible to most Americans – even those with “excellent” insurance – because of cost. The deductibles and co-pays are too high and the bills are outrageous! Obamacare does little or nothing to address this. Based on current price projections, the states’ 10 percent for coverage (in theory) could be enormous, and many citizens still will not have access to services (in practice).
If you want truly universal healthcare, you have to have affordable healthcare. The millionaires in Congress don’t seem to “get” this.
What Bondman & Anne said. We need to prune the thugtree. You would think point blank “shame” would work, but no, that just makes their IQ drop another 20 points!
This is so easy to explain to voters that I am confident that none of these recalcitrant governors will make it through their next election cycle.
I hope that all the Republican Governors refuse the Medicaid money; because then they will not be around very long.
Sarah makes a lot of sense, and she seems to be all alone regarding the opinions on this particular blog.
As far as examining heads, would it be wise for one to buy a product, simply because it comes at a 90% discount? In addition, what if the 90% discount is funded by debt, rather than real wealth?
Is it wise to not give a darn how the 90% materializes?
What if you cannot afford the 10% co-payment?
Don Levit
Hi Don, these days, EVERYTHING the gov does is funded by debt, yes?
The Bond Man:
We have had so much debt for so long, we tend to forget there are revenues coming in also. I believe the federal government spends about 41 cents in debt for every dollar spent. So, let’s be realistic, and not so negative.
Or, do you consider debt a negative?
There are actually many people who consider debt a form of wealth.
They believe, for example, Medicare Part D is fully funded!
There are enough true believers that this belief has a name: The Trust Fund Perspective.
Don Levit
“This is so easy to explain to voters that I am confident that none of these recalcitrant governors will make it through their next election cycle.”
I wouldn’t bet on it. Any political party predicated on an appeal to the worst in people begins each election cycle half-a-lap ahead. Take the fundamental depravity of mankind, and the points. It may not always win, but the fundamental depravity of mankind always covers the spread.
@Sarah – when you are trapped inside the spider web of FIAT $$$$ and fractional reserve banking and vicious taxation schemes, there is no solution to the *cost* of health care. The entire USA economy has been re-organized to fund perpetual war in the Middle East (no talk of *austerity* for them is there? No one is saying that “we ran out of bullets” when the call comes in for a refill!) They get their austerity-free bullets because you have to pay the 25% of any disposable income you have left after the 75% you pay slum lords for rent for a cast for a broken finger. And if that isn’t enough insult added to injury, the IRS gets to FINE you for not feeding the FOR-PROFIT health insurance machine that IS A PONZI SCHEME to support the Welfare Queen in the Middle East! But the population is so well trained now to believe that the PROBLEM is with an individual making the wrong choices!!!! Scheesh….
Yes, health care is so expensive because it’s the part that is subject to austerity, whereas the Welfare Queen of the Middle East is slated for *growth* into infinity and beyond.
Engineers should check out where the leak STARTED and where, and how big, is the pool formed by the leak…yup, there is no hose re-distributing what collected in the pool…”eat S-t and die, you loser”….
Politics (including law) mostly consists of the baser instincts. Of course, the Obama WH lacks the credibility to protest or complain anyhow.
‘A governor could do the minimum required by law or could do better than that. Does the latter trouble you?’
It doesn’t trouble you that he could easily do WORSE? We live in a constitutional republic that was designed a certain way because men aren’t angels and angels don’t govern men. Thus government is restricted to certain ‘enumerated powers’.
Think about how unhappy has been the lot of people who’ve lived under governments not so constrained.
‘For example, the law in my state does not require our governor to give interviews, but he does. Is he out of line? Do you take issue with this?’
Gee, that’s really a poser. Does the law give him the power to change his socks and underwear? Politicians talking is what they do.
‘The underlying problem is cost! Healthcare is not accessible to most Americans – even those with “excellent” insurance – because of cost. ‘
‘Most’? Have you noticed all those hospitals and clinics spread throughout the land?
But, the reason healthcare is more expensive than it needs to be is precisely because most of it is not paid for by the consumers of it. Any product or service that is provided by one party, consumed by another, yet paid for by a third (govt, insurance, wealthy relatives…) will be inefficiently provided. That”s an iron law
“But, the reason healthcare is more expensive than it needs to be is precisely because most of it is not paid for by the consumers of it”
But, the reason defense is more expensive than it needs to be is precisely because most of it is not paid for by the consumers of it.
Hi Don, no I was actually getting at the debt-based fiat money paradigm that has been the rule for the last 100years nearly.
Having managed debt successfully, I am no big proponent of not living within your means, and that includes the government, but the US Constitution clearly provides for the US government to finance its’ expenditures with the issuance of credit and debt, so there is no question the US is acting within legal limitations imposed by its’ own blueprint for governance. Thanks.
If the Republicans win the election, most of these governors presumably will stick with their no Medicaid expansion positions. However, if the Republicans lose, the Tea Party will take a big hit (reflecting many losses in swing states). Furthermore, there will be lots of recriminations in the party over losing an election that on the face of it they should have won fairly easily. In an atmosphere where the party is searching for at least some new positioning and identity, and with no election for at least another two years, I believe that most GOP governors will accept the expanded funding. For them to say so now is bad politics. After an electoral defeat for the party in November, the political price to pay would be minimal. There should be significant support for accepting the Medicaid expansion by Republican-leaning managerial types, especially hospital administrators, and it should translate into measurable economic growth for their states.
“oodles of federal money” ?!?!?!??!
What planet are you on ???
The “oodles” of federal money is NOT federal money…it is TAXPAYERS MONEY !!
And now that we are borroiwng 30% of our annual spending…it’s not even taxpayers money …it’s BORROWED money!!
The federal government is going to entice states into the Medicaid “trap” by paying for a few years…then will gradually renig leaving the states “stuck with the tab” on an unsustainable and growing bill that will (at worst) bankrupt the state finances or (at least) cause massive cutbacks in other areas.
When are you “so-called” economists going to go back to Econ 101, the law of supply and demand?
When something COSTS the consumer more money, it generates a combination of competition and conservation, thus moderating the upward trajectory of prices.
I propose (simplisitcally) now that the Supreme Court has legalized a healthcare mandate TAX, that if someone ends up ends up “on the dole” that’s Medicaid for the liberals. The the government has the right to charge a perpetual lien on the assets and income of the individual, including social security.
Until there are costs and consequences for accessing taxpayer financed medical care, we will not see progress in lowering costs, creating competition, and conservation.
Nancy Pelosi’s “free mediacal care for all model” will bankrupt us all.
Well said, Jeff.
As you and others may know, Social Sexcurity passed constitutional muster, primarily because it was deemed a tax, for the general welfare. The contributions went to the Treasury’s general fund, like all other taxes. And, because the citizen could not tie his contributions to his specific benefits, the tax was for the general welfare.
In the recent ACA decision, this so-called tax, I assume, is a tax, for it is for the general welfare. In reality, it is a tax for the specific welfare of insurance companies. Since when were insurers deemed for the general welfare?
Don levit
What a brain teaser there Jeff, I heard at 42% borrowing costs determine the standard border line determination for hyperinflation, which was crossed during the 08 crisis.
Righto, Jeff.
So when is perpetual war going to get cheaper?
No taxation without representation. I have no representation so we might need to revisit this:
“…..government has the right to charge a perpetual lien on the assets and income of the individual….”
Sullivan, what the hell are you talking about?
Right, there’s not a bit of bait and switch here. It’s not like the federal government will ever reduce their 90% share, right? States should expect that the federal government is going to change the rules a few years down the line because their requirements are unsustainable.
Prudent governors are looking to a future and how much the bills could add up to. And all your name calling and hate mongering can’t change that.
Tea Party doesn’t like other people gaming the system. I It seems to be their exclusive monopoly. There is no problem with subsidies or taxes to pay for those subsidies for Oil/Coal/Gas industry or anything else they (Koch Brothers/Karl Rove etc) deem important. You know government aid is a narcotic once you have a taste you never want to give it up or share it.
Rick Scott is right.
Many federal programs come with wild promises about funding that fall thru. The IDEA regs (special ed) that states must adhere to were going to be fully funded. Now @ less than 10%.
Setting up yet another layer of Dilberts will not make anyone healthier. Allowing medicaid to expand as is might be better for some states.
BTW – Rick Scott ended the rocket docket fast-process foreclosure courts, insisting that foreclosures go thru the court system as law requires.
Many of the subprime and other boom-era fraud mortgages were foisted on poor and/or minority folks. Scott stepped up on their behalf – stalling the banks as they try to seize as many Fla. homes as possible.
Thanks, Gov. More of us kept our homes because of you holding the banks at bay.