Yesterday, I wrote about the proven benefits of the Affordable Care Act’s expansion of Medicaid to provide health insurance to millions of our previously uninsured fellow citizens. By way of background, I began yesterday’s column with the following:
According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.
There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.
The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.
Today, we’ll examine the reasons governors and legislatures in those 12 states give for not accepting the massive federal funding coming with ACA expansion. Tomorrow, I’ll offer an opinion and a plea for building a better system.
But first, we’ll need to set the stage.
The rate of uninsurance in non-expansion states is nearly double that of expansion states.
A word about the uninsured in non-expansion states. As the above chart shows, nearly 22% of them live in rural areas. The majority of these Rurals are registered Republican voters. They are also white/non-Hispanic and less educated than their urban counterparts. Medicaid expansion would be of great benefit to them. But their governors and legislators refuse to expand Medicaid to help these people and the rest of their uninsured populations. Why?
What is even more perplexing is why the rural uninsured continue to vote for people who refuse to help them improve their health care lot in life.
There is another darker result of not expanding Medicaid, and it concerns people of color. People of color, especially the uninsured, have faced longstanding disparities in health coverage that contribute to disparities in health. The states that expanded Medicaid following passage of the ACA saw significant decreases in these disparities from 2010 through 2016; the non-expansion states did not. Beginning in 2017, the Trump administration implemented policy changes that made it harder to qualify for Medicaid. The result was a reversal of progress made during the prior six years; the number of uninsured began growing again, and, once again, people of color were the hardest hit.
Just another example of the cultural and moral divide in America.
Governors and legislators opposing expansion offer 3 primary arguments:
The state cannot afford it.
This is political theatre. The federal government pays 90% of the cost of expansion, the state the remaining 10%. States that have expanded coverage have demonstrated affordability by moving funds from other areas that, because of expansion, will not need as much money. In Michigan, for example, the state budget realized substantial savings in correctional health care and community mental health when some of the expenses of these programs were shifted to Medicaid. Taking into account other economic effects of expansion, such as increased tax revenues from increased economic activity, Medicaid expansion was a net benefit to the state’s budget. Moreover, the Families First Coronavirus Response Act, which was signed into law on 18 March 2020, included a provision for the federal government to assume a larger share of existing Medicaid obligations in every state, freeing up state Medicaid funds for other uses — like expanding coverage. The “We can’t afford it” line does not hold water.
Allowing people to access Medicaid will discourage them from working.
Multiple studies have found no evidence that expanding Medicaid is a disincentive to working. A typical finding is, “We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.”*
Expanding Medicaid will only add more people to a broken system.
Opponents of expanding coverage often deride Medicaid as a low-quality program. Yet a majority of people in the U.S. — Democrats, Republicans, and independents alike—believe that the program is working well. In states that have not expanded Medicaid, a clear majority favor doing so. Most Medicaid enrollees are quite happy with their coverage, reporting higher rates of satisfaction than people with private insurance.
The arguments listed above are the three reasons most often cited by leaders in the 12 non-expansion states for their opposition. There is one argument that goes unexpressed, but is often present: People who are uninsured are uninsured because they lack the money to become insured. They lack that money because they never worked hard enough to get it. They are irresponsible. Consequently, society does not owe them a free health care lunch.
Over the last two days, I’ve tried to counter that “thinking” with clear, hard, proven, factual data. None of it has been opinion (if you ignore my comment yesterday about Senator Ron Johnson, that is). I’ve tried to demonstrate that all the arguments in opposition are nothing more than groundless opinion.
I end with these questions: Is health care a basic human right? Does society owe its poorest decent health care, or must they earn the privilege? How do we answer the murderer Cain’s question in Genesis 4:1-13, “Am I my brother’s keeper?”
We need answers to those questions.
*Leung and Mas, Employment Effects of the Affordable Care Act Medicaid Expansions, 25 March 2018, in Industrial Relations, A Journal of Economy And Society.
Tags: health policy
