Political Animal


February 08, 2013 10:04 AM Medicaid Tipping Point?

By Ed Kilgore

The recent decisions of three Republican governors—Jan Brewer of Arizona, John Kasich of Ohio, and Rick Snyer of Michigan—to go along with the Affordable Care Act’s Medicaid expansion provisions has convinced some observers that the states collectively are reaching a “tipping point” where the remaining holdouts will be under terrible pressure to follow. Here’s how WaPo’s Sarah Kliff puts it:

Many Republicans balked at the expansion when the Supreme Court made the Medicaid expansion optional in its ruling last in the summer. Supporters of the law worried that the opposition could undermine the entire health-care overhaul by shrinking the pool of Americans who would gain coverage.
But six Republican governors have since come to back the program, including Michigan Gov. Rick Snyder on Wednesday and Ohio’s John Kasich on Monday. Arizona Gov. Jan Brewer announced her support in mid-January.
It’s an extraodinary turnaround that suggests the lure of federal dollars could halt Republican obstruction of the health-care overhaul. Twenty-two states and the District are now on board, and 17 others are deliberating. The remaining 11, all with Republican governors, have said no — but observers believe the recent decisions could change some minds.

Well, maybe. Naysayers like Rick Perry of Texas, Bobby Jindal of South Carolina, and Nikke Haley of South Carolina have demagogued this issue to a degree that may make backtracking impossible, and all three may well be vastly more interesting in scoring national conservative brownie points than in making any rational cost-benefit calculations. And some Republican governors, notably Mississippi’s Phil Bryant, are morally offended by the idea of Medicaid itself—never mind an expansion.

But the big test case will be Florida’s Rick Scott, who governs a state that trails only Texas in terms of the impact of its decision on the Medicaid expansion (potentially 1.3 million Floridians might qualify).

Scott is being deliberately cadgy about the Medicaid expansion at the moment. He got caught publicly lying about its cost (though he was only off by a bit over 80%, without considering probably state savings from reductions in uncompensated care), and is clearly using the leverage of his indecision to seek extensive Medicaid waivers from HHS Secretary Kathleen Sebelius (including one allowing wholesale transfer of Florida Medicaid beneficiaries into privately-run managed care plans). His recently released budget doesn’t include funds for the Medicaid expansion, but doesn’t close off the possibility of later amendment.

And then there’s the politics. Scott wants to get re-elected in the worst way, and is very unpopular. With polls showing over 60% of Floridians supporting the Medicaid expansion, it may not be the best time for the governor to cut any Tea Party capers.

So this is the state and the Republican governor to watch. But I don’t think the “tipping point” happy-talk is necessarily accurate. Some Republican governors insist this is not a fiscal decision. Indeed, some are perfectly happy to publicly admit they don’t much care about poor and sick people—or that their idea of “caring” is to make sure they get a chance to show “personal responsibility” for sickness and death.

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.


  • james on February 08, 2013 10:13 AM:

    Ed, make these corrections. Rick Snyder -- name is spelled wrong in second line.

    Also, in the paragraph that begins "Well, maybe," Bobby Jindal is from Louisiana and Gov. Haley's first name is spelled wrong.

  • Russell aboard M/V Sunshine on February 08, 2013 10:19 AM:

    It's really quite simple, really. Are you part of "these United States or aren't you, governors?

  • Russell aboard M/V Sunshine on February 08, 2013 10:24 AM:

    It's really quite simple, really. Are you part of "these United States or aren't you, governors?

  • Robb on February 08, 2013 10:31 AM:

    I wouldn't consider Snyder an indicator of everything.

    He was on the side of implementing ACA all along. In this case, he calculated that sticking with that position would work out better than flopping to the far-right (he has some damage to repair from the RTW fiasco)
    Snyder is usually hated more by Republicans than Democrats because he's not a purist. Hell, I voted for him in the primary (we have open primaries) because his opponents were wingnuts.

    So when using Snyder as a variable, remember:
    He ran as a moderate.
    He was elected by popular vote by a light-blue state.
    He regularly clashes with the GOP in the legislature.
    Conservatives hate him more than liberals do and he usually appeals to moderates.

  • Sue on February 08, 2013 10:47 AM:

    What about Pennsylvania??

  • bigtuna on February 08, 2013 11:12 AM:


    Republican Gov. Tom Corbett, in a letter sent today to U.S. Department of Health & Human Services Secretary Kathleen Sebelius, said that "The Medicaid program in Pennsylvania is on an unsustainable path. ... I firmly believe we can serve more of our citizens in Pennsylvania, but only if we are given the independence and flexibility to do so.
    "At this time, without serious reforms, it would be financially unsustainable for Pennsylvania taxpayers, and I cannot recommend a dramatic Medicaid expansion," said the letter, released today as part of the governor's budget address.

    Read more: http://www.post-gazette.com/stories/local/state/governor-takes-a-pass-on-expanding-medicaid-673491/#ixzz2KKBM4qVd

    According to http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap#lightbox/1/

    UT, KS, NC, TN, WV,IN, WI, FL and AK have yet to decide.

    In looking at the map, we are going to have more of the south is at the bottom of the pile BS again.

  • mb on February 08, 2013 11:38 AM:

    I don't see how governors like Bryant here in MS are going to be able to resist pressure that is bound to come from their states' hospital associations. As I understand it, disproportionate share payments (DSPs) will stop with the expansion of Medicaid and whether a state participates or not, the DSPs will stop. DSPs are intended to mitigate the costs of uncompensated care rendered under the EMTALA requirements.

    Under ACA, DSPs are replaced by Medicaid expansion but if the state opts out, hospitals are still required to fulfill EMTALA without any cost mitigation at all. I cannot imagine the MS Hospital Assoc. is going to take that lying down.

  • Mimikatz on February 08, 2013 12:10 PM:

    The logical next step for the Perry-Jindal-Haley position is to release hospitals from the obligation to provide emergency care. This was enacted during the Reagan Administration after a series of high-profile patient dumping scandal with people dying in ambulances or on the hospital doorstep after being refused care. This is probably what the GOP really wants. Who will be the first to call for it?

  • dp on February 08, 2013 4:13 PM:

    Would that Bobby Jindal were of South Carolina rather than Louisiana!

  • Blue Girl on February 08, 2013 4:47 PM:

    They can't do that, Mimikatz, although I wouldn't put it past them to try. First off, the people working today wouldn't turn a patient away. For 30years we have treated first and asked questions about payment later. Secondly, EMTALA is a federal law, and any ER personnel who refused to render care, and a patient died, would face federal charges and the state wouldn't be able to step in and save them.

  • pjcamp on February 09, 2013 12:58 AM:

    Jeezus H. Christ! There's ANOTHER Bobby Jindal? He's like a damn mushroom.