The Moral Question of the Medicaid Expansion

In the last four years, we've seen a lot of reflexive, frankly dickish anti-Obamaism from Republicans at all levels. Much of it is relatively harmless; when some knuckle-dragging congressman goes on talk radio to air his suspicions that Obama's birth certificate is a forgery, there may be some chipping away at the President's legitimacy, but no one's life is affected directly. But there are some cases where Republicans are willing to do direct, substantial, even life-threatening harm to thousands or even millions of people, for no other reason than to demonstrate their unflagging hatred for the man in the Oval Office.

I'm talking here about the coming expansion of Medicaid, which didn't get discussed much during the campaign, but which is the most profound effect of the passage of the Affordable Care Act. As you'll recall, when the Supreme Court upheld the individual mandate, it gave a gift to Republicans too, saying states could opt out of the law's expansion of Medicaid, under which anyone earning up to 133 percent of the federal poverty level would be eligible. Especially for poorer, Southern states, the Medicaid expansion is a huge boon, particularly since the federal government will be paying all the cost of the expansion in the first few years, and nearly all the cost from that point forward. Those states currently have absurdly stingy eligibility requirements for the program, making it so that if you earn enough to live someplace other than your car and eat as much as two meals a day, you're probably ineligible. So here comes the federal government, saying to the states, "We're going to pay to get all these poor people in your state health insurance, which will save the state money in uncompensated care, and make for a healthier, happier, and more productive population." To which many states have replied, "Screw you, Obama!"

Or more properly, "Screw you, poor citizens!" Let's take, for example, Texas. They have the highest rate of residents without health insurance in the country, at 26 percent. Under the Medicaid expansion, 1.4 million Texans would get health insurance, and the federal government would pay for it all. And Governor Rick Perry refuses. There's no need to mince words: That decision will literally kill people. There will be Texans who will die because they don't have insurance, when Rick Perry could have saved their lives but chose not too, because he thinks Barack Obama is a socialist. Sarah Kliff posted a nice map showing where states have announced they'll refuse the Medicaid expansion, and as you can see, it's all states with Republican governors, mostly in the South. They were all hoping that Mitt Romney would win and all of Obamacare would be undone. But now that the election is over, they'll take whatever opportunity they can to show how displeased they are

Now, if you ask Perry (or the other governors), he'll say that he doesn't think Medicaid is a good program, and he'd prefer some kind of private-sector solution (he'll also say he wants Medicaid to be block-granted so he can have "flexibility," which is code for "being able to toss people off the program"). But there is no super-terrific private-sector solution in the offing to get poor people health coverage. Maybe some day someone will come up with one, but at the moment it doesn't exist.

When a policy change is being debated, it's not unreasonable to say that you oppose this particular change because the change you'd like to see is a different one, even if your preferred change isn't going to happen any time soon. But that's not the choice. The choice these governors face is between people having no health insurance, and people getting covered through Medicaid. And what they're saying to their own citizens is: I'd rather you have no health coverage than get covered through a government program. And if you get sick or get in an accident, well, maybe you should have thought of that before you went getting all poor.

There are people who believe that eventually even the likes of Rick Perry will be unable to resist all the money the federal government is offering, so these governors will bluster for a while but take it in the end. But I'm not so sure. That would require them to give a crap about the welfare of the people of their states. And there isn't a whole lot of evidence for that.

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