Political Animal


July 10, 2012 10:20 AM Medicaid Expansion: We’ve Been Here Before

By Ed Kilgore

For those (like me) with a pessimistic view on the willingness of Republican governors to stop lying to themselves and their citizens about the fiscal—not to mention moral—case for implementing the Medicaid expansion authorized by the Affordable Care Act, a history lesson is in order. States have faced this sort of decision before—when Medicaid was first established, and when the Childrens’ Health Insurance Program—better known as CHIP—was set up a generation later. And there was plenty of resistance in both cases, as Sarah Kliff explains at Wonkblog today:

Medicaid got a chilly reception when it launched in January 1966. It was up to the states to decide whether to participate and only six initially signed up: Hawaii, Illinois, Minnesota, North Dakota, Oklahoma and Pennsylvania. Twenty-seven followed suit later that year. Across the country, governors weighed the boon of new federal dollars — Washington would foot half of Medicaid’s bill — against the drawback of putting state money into a new program….
Over time, however, the lure of federal dollars proved strong enough to win over resistant states. Eleven joined the program in 1967. Another wave of eight, largely Southern states came on board in 1970. Arizona proved the last holdout, not joining Medicaid until 1982.

CHIP was the most dramatic of a number of efforts by Congress to build from Medicaid by offering states a better match rate:

States would have to pay about 35 percent of the program’s bill. That was a better match that Medicaid’s regular contribution of 50 percent, but still left states with some financial responsibility - and a commitment to participate in a new government program.
That made CHIP a subject of heated debate in Texas, where the Democratic-controlled legislature clashed with then-Gov. George W. Bush over whether to participate.
“States like Texas sat on the opportunity for a while,” said Jason Cooke, who served as Texas’ first CHIP director. “The governor was not interested in calling a special session to get it authorized and, frankly, didn’t want the CHIP program authorized in the first place.” Texas did eventually enroll, with Bush signing legislation authorizing the program in 2000. By the end of that year, all states had adopted the CHIP program.

ACA’s Medicaid expansion offers a vastly better match rather than CHIP. But then again, if George W. Bush was the epitome of conservative governors in the late 1990s, his protege Rick Perry—who punctuated his presidential announcement speech with a complaint about poor people not paying taxes, and has flirted with secessionist rhetoric—is more typical of the current breed, who find it politic to openly despise the needy as looters and parasites. So while it may be just be a matter of time before the fiscal insanity of turning down ACA’s Medicaid expansion fully sinks in, it may be a long time before the moral calculus changes and it’s no longer fashionable among conservatives to turn a blind eye to the uninsured.

Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.


  • c u n d gulag on July 10, 2012 10:26 AM:

    Don't make fun of Rick Perry.
    On top of being epically stupid, he's got a mental disease.

    It's call "Conservatism."

    And the symptoms are:
    1. Automatic opposition to AND thing Liberals and Democrats are for.
    This results in more money and power for the wealthy and powerful.
    And a lot of followers who sit around nose-less, since they cut them off to spite their own faces.
    And THAT'S why none of the followers can tell that this ideology stinks for all but the rich and powerful!

    2. And doing reflexive spine-snapping 180-degree turns whenever the Liberals and Democrats use THEIR Conservative policies, figuring doing this is as at least better than doing absolutely nothing - and making that a starting point for progress in the future.

    3. And a willingness to let your country, your state, and your citizens die - all for the profit and power of the cronies of the politicians, who'll then reward the politicians.

    And Rick Perry is as fine and example as you can find of "Homo Conservatous Moronous."

  • j on July 10, 2012 10:35 AM:

    Please folks, if you read nothing else today -on this subject, go to pOLITICUS and read of the consequences of the republican states dropping out of the ACA.

  • Joe Friday on July 10, 2012 12:15 PM:

    The moral or even fiscal arguments will be irrelevant once the hospitals start telling the citizenry they will HAVE TO CLOSE. Then you're gonna see some old fashioned flip-floppin' going down.

  • c u n d gulag on July 10, 2012 12:28 PM:

    Joe Friday,
    Let's see the outrage at Gov. Scott of FL, who just shut down the only TB Hospital in the state, during the worst TB epidemic in the state in 20 years.

    People should be screaming for his bald head!

    Want to bet no one will complain, unless they know someone who has TB?
    And those are likely to be poor people, so the MSM and the Conservatives in government don't give a rat's @$$!!!

  • jsjiowa on July 10, 2012 12:36 PM:

    I've heard state legislators complain for years about the amount of the state budget that goes to pay for Medicaid. They've often looked for ways to trim those eligible, rather than expand it, especially when Republicans control state government.

    Now with a Republican Governor, that's the message that's being heard -- that we can't afford the ongoing dollar commitment (and risk that the feds will decrease how much they pay). So far, the Governor is ignoring that the hospitals want this expansion. http://blogs.desmoinesregister.com/dmr/index.php/2012/07/09/in-press-conferences-evidence-that-democrats-and-republicans-are-worlds-apart-on-health-care-reform/

    Add that this morning's CNN appearance by one of our Congressmen touting that too many lower-income Americans are not doing their fair share to contribute to GDP (really -- http://blogs.desmoinesregister.com/dmr/index.php/2012/07/10/iowas-steve-king-too-many-non-working-americans-arent-doing-fair-share/ -- Note especially the part of the interview where he suggest that, due to various welfare programs, an American can not work and still have a middle-class standard of living!!)

    If the Democrats win control of state government this fall, maybe we'll see a change. Otherwise, I don't think so.

  • weboy on July 10, 2012 2:44 PM:

    I like Sarah Kliff's work a lot, but this history lesson is really not the point; the expansion of Medicaid to 133% of poverty for everyone is an enormous, expensive expansion that was poorly thought through, sloppily put together and is generally unrealistic. Medicaid, as it is currently structured (i.e., without even expanding it) required a significant overhaul. The most basic problem is that its reimbursement rates are horrendous, and many doctors simply refuse to take patients. Hospitals, yes, like reimbursements that are better than nothing (and remember why we wanted to end fee for service?) , but whether hospitals can pressure states to really change refusals to take the expansion are an open question. And if it were such a slam dunk, a hospital exec (and Medicaid exploiter) like Rick Scott would seem prime example of rethinking it. So far, he hasn't.

    The Medicaid expansion was really the biggest, most fantastical element of the ACA, and I'm dismayed and frustrated by how many otherwise thoughtful lefties have a remarkable blind eye when it comes to how poorly we do as a nation helping the poor. Medicaid, as constructed, is terrible, expanding it enormously, as a fig-leaf way of achieving "full coverage" (when the coverage for the poor will be both wildly expensive and not necessarily helpful). It's only now, more than a week late, that some liberals have started to comprehend the real, Reaganite mischief of the Roberts decision as applied to Medicaid. The moment to really have challenged the lousiness of the Medicaid expansion was when ACA was lurching towards passage; now, with all these objections and all this politicization, nothing really useful will come of it: some states will start the expansion, and others will resist.... long before we reach some "tipping point" where non-participating states cave in, we will face an enormous financial crisis in Medicaid reimbursements to doctors and hospitals. And the lack of attention and thought given to that reality is what I find really depressing.

  • Joe Friday on July 10, 2012 3:39 PM:

    c u n d gulag,

    "Let's see the outrage at Gov. Scott of FL, who just shut down the only TB Hospital in the state, during the worst TB epidemic in the state in 20 years. People should be screaming for his bald head!"

    As you lamented, the vast overwhelming majority of Floridians do not have TB, so there will be no outrage. But the regular major hospitals, which made the deal that they would stop receiving federal monies in exchange for all the new patients WITH INSURANCE COVERAGE THEY COULD BILL could be forced to close.

    THAT people will be screaming about.