Medicaid Expansion and the Right. Part 2: The Role of Conservative Think Tanks

About Owen Jennings

This week, the interns at PRA are posting a series of blog posts examining the recent right-wing opposition to Medicaid expansion. In June 2012, The Supreme Court found the expansion of Medicaid an unconstitutional coercion of states’ rights, leaving the decision firmly in the hands of the states. Medicaid expansion is set to go in effect in this month, and as of now, only 25 states and Washington, D.C., are moving forward with the expansion. Expanding Medicaid is a necessary provision of the Affordable Care Act, and the 25 remaining states are ensuring that large portions of the population will still have no access to affordable healthcare. These blogs seek to explain both where opposition to Medicaid expansion originates, and why it might be in the interest of the politicians on the Right to accept the proposed expansion.

Read Part 1: Using Clinton-Era Talking Points Against Families & Minorities
Read Part 3: The Long-Term Costs and Economic Benefits
Read Part 4: Alternative Models


The Supreme Court’s decision to not to allow the federal government to mandate Medicaid expansion nationwide has pushed the debate down to the state level, and the resulting rhetoric used by governors and legislators opposing Medicaid expansion bears more than a passing resemblance to the arguments used by Right-Wing think tanks. These arguments have somehow turned the offer of a largely federally funded program into an economic disaster for states. They question the economic benefits and viability of expanding Medicaid coverage, often ridiculing any suggestion to the contrary. States following the logic of these messages, deciding not to expand Medicaid coverage, ensure that millions of Americans remain uninsured, caught between the income threshold for Affordable Care Act (ACA) subsidies, and the upper limit of Medicaid in their state.

Right-Wing think tanks such as the Heritage Foundation and FreedomWorks (along with all of their affiliate state-based organizations in the State Policy Network) contend that expanding Medicaid is unaffordable, and that the federal government cannot be trusted to uphold its promise to cover the expenses of Medicaid expansion. In a September 2012 report, the Heritage Foundation argues that “the Medicaid federal match rate could be lower in the future,” suggesting the federal government will likely eventually reduce its funding below the 90 percent promised (100 percent coverage for the first three years). The report also highlights “costly” administrative fees associated with the expansion, but fails to mention what exactly falls under the vague parameters of “administrative.” Another Heritage Foundation report argues that “state lawmakers have no guarantee future Congresses will keep that promise,” adding that there wouldn’t be any way for states to opt-out of the expansion if the federal government did renege on its promise.

FreedomWorks takes an equally damaging approach, sarcastically mocking the suggestion that the expansion of Medicaid could cost nothing, using a skewed view of Ohio as their example. In another instance, they attack the expansion in Arkansas, once again using cost to the state as their main objection to Medicaid expansion. Both of FreedomWorks and Heritage have consistently laughed off any suggestion that Medicaid expansion would be economically viable for states, that the federal government would pay for it, or that it would actually benefit the people it covered. More dangerously, they have built a framework of arguments, in some cases backed up by skewed statistical reports, which can be used by politicians in defending their rejection of a Medicaid expansion.

Touting the same set of glaringly unsubstantiated arguments, this continuous stream of opposition to Medicaid expansion seem to have influenced Right-Wing politicians at state level. Governors and legislators across the US echo the work of the Heritage Foundation’s and other like-minded conservative groups.

Despite the volume and fervor of protest coming from politicians, governors and state legislators, a select few arguments dominate the debate, arguments that seem to be derived from assertions made by think tanks like FreedomWorks and the Heritage Foundation. Some governors, such as Governors Robert Bentley (AL) and Mary Fallin (OK) claim their states would not be able to afford the expansion of Medicaid. In one case, Fallin misstated the cost to the state, claiming “for the first three years of the cost, the state would pick up 10 percent of expanding the Medicaid services of our state.” Gov. Phil Bryant (MS) also highlighted additional administrative costs not covered by the federal government, a point consistently made by the Heritage Foundation. Gov. Nathan Deal (GA), Gov. Pat McCrory (NC), and Gov. Sean Parnell (AK), on the other hand, have expressed concern that the government will renege on its promise to fund 90% of the expansion. Parnell, in his statement declining Medicaid expansion, said “[t]he decision comes down to this: Can states trust the federal government to not cut and run on its share of the cost?” McCrory, shortly after his state’s ACA implementation, spoke of a “long-term concern regarding the federal government’s continuing of its obligation for matching funds,” adding that, supposedly due to the ACA, North Carolina’s system is broken and needs to be fixed before the state even considers Medicaid. Some go as far as to call both the ACA and Medicaid broken, pressing for the elimination of both. Others simply argue that an expansion is wrong in principle. Gov. Rick Perry’s (TX) main strand of argument centers on what he believes is a violation of state sovereignty. He asserts the federal government would “make Texas a mere appendage of the federal government when it comes to health care.” FreedomWorks similarly focused on Medicaid’s expansion’s supposed infringement on state sovereignty. Most rejections of the expansion incorporate a selection of these responses.

Together, these arguments form the base of an information struggle, with think tanks and politicians trying to position expansion as a dangerous blow to the still-recovering U.S economy.  With the near total federal funding of the expansion, one might think that this is a difficult argument to make, but roughly half of states appear to have taken it as truth. Their arguments rely upon hypothetical situations without precedent. Considering many of the states declining Medicaid expansion also benefit from more federal spending than is raised in them, not trusting the federal government’s spending promise on Medicaid is clearly ideologically driven.  However absurd, vague, or speculative these politicians’ excuses for not expanding Medicaid may be, they leave millions of people with no access to healthcare.

Owen Jennings was a Fall 2013--Spring 2014 intern for Political Research Associates