On Medicaid, Republicans Explore New Moral Depths

As the lawsuits challenging the Affordable Care Act worked their way up to the Supreme Court, I always found the challenge to the expansion of Medicaid to be the strangest part. Quick context: the program provides insurance for poor people, splitting the cost between the federal government and the states. But the current rules say that each state gets to set its own eligibility standards, which meant that if you live in a state run by Democrats and you're poor, you can get Medicaid, but if you live in a state run by Republicans, you have to be desperately poor to get Medicaid. For instance, in Mississippi, a family of four has to have a yearly gross income below a princely $9,828 to qualify. Because if a family is living high on the hog with their $10,000 a year, they aren't really poor, right?

Fortunately, the Affordable Care Act fixed this, by changing Medicaid so that everyone with up to 133 percent of the federal poverty level ($30,657 for a family of four) would qualify. And to make things easier on the states, the bill provided that the federal government would pick up almost all of the tab. The federal government pays 100 percent of the cost of paying for the new enrollees through 2016, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent from then on. In other words, the federal government is saying to states, "Here's a bunch of free money to insure a whole lot of your citizens, which will make them healthier and more productive." And almost every state run by Republicans replied, "How dare you do such a thing to us! It's unconstitutional! We're suing!"

And unfortunately, the Supreme Court gave them the right to turn down the money, so each state gets to decide whether it wants to accept the expansion. The irony is that this change in Medicaid is much, much more valuable to the states that have been the stingiest with Medicaid up until now. Massachusetts, for instance, already sets Medicaid eligibility at 133 percent of the poverty level, so they get no new money. It's the Republican states with Scroogian eligibility who will get the most benefit, insuring millions of their citizens at little cost. But they're the ones who don't want it.

It's pretty obvious that many Republicans wish there was no such thing as Medicaid at all. But if they have to tolerate poor people getting health care, they want to make sure as few of those poor people get it as possible. Because after all, if you can take your kids to the doctor whenever they get sick, how are you going to learn that being poor proves how sinful you are?

When this all comes down in 2014, the Republican governors and legislators who choose to opt out of the Medicaid expansion shouldn't be allowed to claim that it's a budgetary issue, because it isn't—it's free money, as far as their state budgets are concerned. They're already trying. Here's Phil Bryant, the governor of Mississippi, saying that the state doesn't have the money to cover the estimated 330,000 people in the state who would get insurance paid for by the federal government. Here are Republican officials in Florida, where around a million people could get coverage under the Medicaid expansion, pleased as punch that the Court gave them the opportunity to say "No coverage for you!" to those poor Floridians.

So these Republican officials will be saying to their own citizens, "The federal government is offering to give you free health insurance, but we won't let you have it. Your health is less important than us making a statement about how much we hate the welfare state and how much we hate Barack Obama and everything he touches." They believe that it's better for a person to have no insurance at all than to get insurance from the government. That position is morally vile enough in the abstract, but when they're actually confronted with a choice to make about whether to allow their citizens to have health insurance, some of them are going to say no. I struggle to find words to describe how despicable and cruel that is.

Now, it's possible that once that money is actually being offered, the states will all say yes. That's what Nancy Pelosi argued yesterday. But that depends on the Republican leadership of those states actually giving a crap about their poor citizens. Let's just say we should believe it when we see it.

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