Medicaid Expansion and the Right. Part 3: Long-Term Costs and Economic Benefits

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 2: The Role of Conservative Think Tanks
Read Part 4: Alternative Models


As Republican Governors cite fiscal responsibility in their refusal to participate in the Medicaid expansion, independent research and precedents in other states expose their arguments as extraordinarily selective. Though the expansion will increase state Medicaid expenses, they neglect to acknowledge the correlation between having fewer uninsured citizens and overall state health care expenses.

While the Congressional Budget Office predicts a menial 2.8 percent increase in Medicaid costs for participating states, that increase is misleading because it does not factor in other  “savings that state and local governments will realize in healthcare costs for the uninsured.” Having more residents covered by Medicaid will help offset the amount states pay in expenses covering health costs for the uninsured, such as hospital fees.

According to a study by the Urban Institute, in 2008 state and local governments had to cover $10.6 billion worth of fees associated with healthcare services for the uninsured. The Urban Institute estimates that overall savings for each state that expands Medicaid will be between $26 billion and $52 billion from 2014 through 2019, noting that “total state savings would exceed states’ new costs.” Essential to consider is that savings resulting from expanded Medicaid coverage will continue to grow over time. As the Center on Budget and Priority Policies points out: “By shrinking the number of uninsured people and having the federal government pick up the overwhelming bulk of the tab, the Medicaid expansion will ease cost pressures on states stemming from uncompensated hospital care, mental health care, and other health care services.”

While we will likely continue to hear Republican Governors cite unfounded cost structures in their opposition to Medicaid expansion, other states have taken the initiative to reform their Medicaid systems before the expansion begins this month. Realizing the potential of Medicaid expansion, Massachusetts began reforming its health care system years before the Affordable Care Act was conceived. Other states, such as California and Minnesota, have begun implementing their own expansion to ease the transition into the new Medicaid system, before they even receive increased federal funding. These states assist us in understanding the long-term impact of expanded Medicaid coverage.

Successful Precedent: Health Care Reform in Massachusetts

In 2006, incumbent Governor Mitt Romney signed into law a comprehensive reform of the Massachusetts healthcare system, with the intention of providing near universal healthcare coverage to all state residents. From 2006 to 2010, the national average of uninsured Americans increased from 17.1 percent to 18.4 percent, but during the same time, the rate of uninsured residents in Massachusetts decreased from 10.9 percent to 6.3 percent, coming in nearly 12 percent below the national average. Massachusetts also witnessed an almost instantaneous impact on state healthcare costs. A study by The Massachusetts Center of Healthcare Finance and Policy noted in the first year of the states’ health reform implementation, there was a 38 percent decrease in spending on healthcare for the uninsured. The decrease in spending directly coincided with the decrease in uninsured residents, and the state has continued to see a decrease in health costs in the concurring years.

In taking a long-term approach to healthcare, Massachusetts was able to both decrease costs, while at the same time provide thousands of previously uninsured residents with coverage. Given the fact the decreased rate of uninsured was found through the MassHealth Medicaid program, there is little evidence to suggest the reforms in Massachusetts would not result in similar success throughout other states.

California’s Head Start to Medicaid Expansion

Due in part to its large population, California has by far the highest rate of uninsured people in any state, with over 7.1 million residents currently living without coverage. Governor Jerry Brown has been one of the more vocal supporters of Obamacare, announcing the day of the Supreme Court Ruling which upheld the law in June of 2012 that “today’s dramatic Supreme Court ruling removes the last roadblock to fulfilling President Obama’s historic plan to bring health care to millions of uninsured citizens.”

Not only were Brown and other Californian state legislators supportive of Medicaid expansion, they also decided to begin expanding the Medicaid program before the official expansion begins in January. Early expansion was viewed as an opportunity to make an efficient transition into the new program, an advantage seen by state legislators as being well worth the short-term increase of cost. As Peter Harbage, a consultant who worked with California on its Medicaid expansion, posited, the goal was to “start getting [the California population] into Medicaid and also get Medicaid ready to care for them.”

Brown, along with many other state officials, hopes that California can be the poster child for a successful transition into the new system, and believes California’s results will show the long-term benefits of Medicaid. Brown’s confidence in the early transition is easily recognizable, in an official statement he asserted “the rest of the country is looking to see how we did it.” Additionally, State Senate Health Committee Chair Ed Hernandez commented on the long-term financial benefits of the expansion, noting that the increased federal funds will “will trickle back into the economy as we address a segment of the population so much in need of healthcare.”

California has already welcomed 400,000 new enrollees to its state Medicaid system, and expects the number to continue rising quickly, as their are 1,873,000 residents who did not meet the previous criteria to receive coverage, but who now qualify for Medicaid.

The economic arguments against expanding their own Medicaid programs by conservative Governors and state legislators neglect to factor in the long-term benefits of expanding Medicaid coverage. They use only economic talking points that push forward their case against Medicaid, and refuse to look at the broader implications of how reforming the system will bring down health costs in the long-term. Expanding Medicaid is a long-term investment, which, in part, explains why the federal government would carry the financial burden for the first three years. If the Massachusetts system is any indicator, the states that participate will already see savings by the time they are required to cover a percentage of the expansion costs.

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

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.

Medicaid Expansion and the Right. Part 1: Using Clinton-era Talking Points Against Families & Minorities

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 2: The Role of Conservative Think Tanks
Read Part 3: The Long-Term Costs and Economic Benefits
Read Part 4: Alternative Models


Part 1: Using Clinton-era Talking Points Against Families & Minorities

Gaining perspective on the rollout of the Patient Protection and Affordable Care Act (ACA) can be difficult when we are embroiled in the day-to-day politicking that accompanies it. The media frenzy surrounding both the federal shutdown and the ACA’s chaotic online launch pushed all-important issues to the back burner. Among them is the fact that nearly 5 million impoverished adults are going to be left uninsured because their states have refused to expand Medicaid coverage.

This “Medicaid gap” leaves individuals who make too much to money to qualify for Medicaid, but not enough to receive health care subsidies, floating in an area where they aren’t eligible for insurance. As a report by the Kaiser Family points out, “Nearly half (47%) of uninsured people of color with incomes below the Medicaid expansion limit reside in the 21 states not moving forward with the expansion at this time.” It’s no coincidence that states like Alabama, Louisiana, and Texas, where racial disparity is already glaring, are leaving more ethnic minorities stranded than any other state. Currently, six out of 10 Blacks live in states not expanding Medicaid. While 38 percent of Mississippi’s population is Black, they account for more than half of the states’ poor and uninsured adults.

In addition to this, withholding Medicaid expansion presents an opportunity to further disenfranchise both women and the LGBTQ community. Pre-ACA, individuals with HIV had to have “a disabling AIDS diagnosis” in order to qualify for Medicaid coverage, and non-pregnant women did not typically qualify for Medicaid. These requirements are waived for states that accept Medicaid funding and expansion, so the ability to deny Medicaid presents yet another outlet through which hardline conservatives can propagate discrimination.

As the ACA is rolled out this month, an examination of strategies and talking points the Right has previously used against legislation which would have enfranchised women and minorities through means similar to current Medicaid expansion can help predict what we can expect from the Right.

The Equal Rights Amendment

The Equal Rights Amendment, (ERA) which on a whole guaranteed equal legal, political, and economic rights for women, was passed by the Carter administration. It then went to the states for ratification during the Reagan administration. The Right’s crusade against the amendment, led by Phyllis Schlafly, founder of the anti-feminist Eagle Forum, was a major factor in preventing the ratification. The vote eventually fell three states short of approval.

In her push against the amendment, Schlafly claimed that by discontinuing to give the “weaker sex” privilege, the ERA would end “civilization as we know it” and was quick to claim that the “ERA means abortion funding, means homosexual privileges, means whatever else.”


Though the landscape has shifted, the arguments remain the same. Members of the Religious Right are more often than not mobilized by their fear that legislative measures threaten family foundations. Schlafly’s arguments proved effective during the Carter and Reagan Administrations, and these same arguments now put a holistic rollout of Medicaid expansion in jeopardy. Her “in defense of the traditional family” argument is now utilized by conservatives against Medicaid’s expansions attempts to enfranchise members of non-traditional families (as defined by the Right).

Kevin Kane of the conservative think-tank Pelican Institute asserted in a post titled “The Trouble With Medicaid,” that “these programs and their incentives have contributed to the demise of marriage and the traditional family unit, to the detriment of the children that are raised in unstable environments, lacking the demonstrable benefits of a two-parent family,” adding that the “social costs” outweigh any benefits afforded by the expansion. Along these same lines, Terence P. Jeffrey, editor in chief at CNS News and former executive director of the American Cause, goes as far as to claim that Medicaid expansion “rewards people who don’t marry, don’t work and don’t take care of their own children. It punishes people who do marry, work hard and take care of their own children.”

Both men are referring, of course, to a traditional family, completely rejecting the fact that the family has evolved far past a man, a woman, and her children, and refusing to acknowledge that such families deserve just as much support and protection.

Clinton Administration Health Care Reform

The demise of the Clinton Administration’s plan for universal health care is widely attributed to William Kristol and the Project for the Republican Future. Chairman of the organization at the time, Kristol distributed a memo to Republicans warning that success of the reform would “signal a rebirth of centralized welfare-state policy at the very moment we have begun rolling back that idea in other areas. And, not least, it would destroy the present breadth and quality of the American health care system, still the world’s finest. On grounds of national policy alone, the plan should not be amended; it should be erased.” Without context, it would be difficult to discern whether this comment regarded Clinton-era healthcare reform or Obama-era healthcare reform.

The memo, which can be read in its entirety here, outlines strategies and talking points that can be used against the Clinton administration’s push for universal health care. Fast-forward two decades, and the “memo” against the ACA comes in the form of a playbook. Distributed to all members of the Republican Party, it’s full of across-the-board strategies for attacking the Affordable Care Act (a.k.a. Obamacare). Talking points around Medicaid include claims that the expansion of coverage to childless adults will end up “diminishing resources for vulnerable populations.” Ed Haislmaier of the Heritage Foundation attacked childless adults in this context, stating they “are not vulnerable poor people” and suggested that if they had full time jobs, they would be covered by health insurance subsidies. He dismissed their issues as “not really healthcare issues,” but economic issues. Such rhetoric is a testament to both the strong ideological underpinnings of the resulting health care gap, and brings forth concern that the gap will perpetuate bias against anyone who makes the choice to not have children.

Looking Forward

History proves that progress towards comprehensive healthcare for non-traditional families (as defined by the Right), the poor, and minorities can be greatly hindered by the Right. Their mobilization of financial and moral arguments have proven to be effective and are advancing with fervor, as evidenced most recently by the attacks on reproductive health funded by the Koch Brothers and a libertarian driven resurgence of neo-confederacy.

Key players of the Right have been able to influence the social stances of moderate Republicans by appealing to both their economic sensibilities and a strong attachment to the (distorted) ideas of “liberty” and “traditional family.” This is becoming ever more pervasive and dangerous in our current political climate as partisan divisions grow wider.

As we look towards both the rollout of the ACA and the 2014 and 2016 elections, the closing paragraph of Kristol’s memo warrants serious consideration. In it, he calls for the complete political defeat of the Clinton healthcare proposal, asserting that the “rejection by Congress and the public would be a monumental setback for the president; and an incontestable piece of evidence that Democratic welfare-state liberalism remains firmly in retreat. Subsequent replacement of the Clinton scheme by a set of ever-more ambitious, free-market initiatives would make the coming year’s health policy debate a watershed in the resurgence of a newly bold and principled Republican politics.” These “newly bold and principled Republican politics” are on the rise again, and though the issues may slightly change, the strategies remain the same.

Sharone Belt: The Obamacare Story You Won’t See In The News

If you watch cable news, you’ve probably seen story after story about Americans losing their insurance plans thanks to the Affordable Care Act (ACA), or “Obamacare.” Despite the passage of the ACA into law in 2010, and despite the Supreme Court’s decision in 2012 to uphold the legislation, and even despite the failed attempt to use a government shutdown as a bargaining chip—Right-Wing Republicans in Congress, governors’ mansions, and state legislatures are continuing their push to blame Obamacare for Americans losing health coverage.

But what about the Americans who didn’t have any health insurance to begin with, and are now being denied acceptance into Medicaid by those same conservatives? There are five million of them, people who have jobs but aren’t paid enough for private health insurance, being left out in the cold by the Right-Wing. On cable news, you don’t hear about people like Sharone Belt in North Carolina, who is being denied healthcare thanks to conservatives.

These are the stories we cannot in good conscience ignore.

Sharone Belt, 47, can't get health insurance because her state refused to expand Medicaid

Sharone Belt, 47, can’t get health insurance to cover her diabetic neuropathy because her state refused to expand Medicaid

Sharone Belt is 47 years old and lives in Hickory, North Carolina. She’s a deacon candidate at her church, collects donations for the local homeless shelter, and volunteers for the Special Olympics and Make-a-Wish Foundation. Sharone took some college classes when she was younger, but even with help from grants and student loans, she was priced out of her education pretty quickly. She now works as a balloon twister at children’s parties and restaurants to make ends meet.

“It’s not a job that pays very well,” says Sharone, “but I love working with the kids.”

Picking up as many gigs as she can, Sharone has managed to get herself just above the poverty line, making a little too much to qualify for Medicaid under the old system, but far too little to be able to afford private health insurance. Sharone also suffers from diabetes, which has led to diabetic neuropathy (nerve damage) because she can’t afford the medications she needs. It’s a particularly difficult thing for her to work with, given her profession.

“I tried to use the free clinic in town,” says Sharone, “it took me six months just to get an appointment, and when I did get in, the medications I need are so expensive the free clinic wasn’t even able to get them for me.”

When the Affordable Care Act was passed, Sharone thought maybe there was finally some light at the end of the tunnel. “I was so excited, I thought maybe I could finally get my health back on track.”

Last week, Sharone found out that North Carolina is one of the 25 states refusing to expand Medicaid to cover people, like her, who are just above the poverty line. Back in March, conservative Governor Pat McCrory signed legislation that blocked Medicaid expansion for 500,000 North Carolinians, like Sharone, who don’t make enough money to purchase healthcare on their own, but don’t qualify for Medicaid, either. According to a report from the state’s Department of Health and Human Services, Medicaid expansion in North Carolina would have not only provided coverage for 500,000 low-income Tar Heelers but would also have added tens of thousands of jobs thanks to the injection of federal dollars. McCrory’s decision also caused a hospital in Belhaven to close, after it couldn’t keep up with unpaid medical bills from low-income patients.

Conservatives argue participation in Medicaid expansion, allowing those who make up to 133 percent of the federal poverty limit access to the healthcare program, would bankrupt states. The claim has been repeated in media outlets around the country, despite policy experts debunking it as a conservative myth being perpetuated by ideological beliefs rather than facts. The ACA actually covers the cost of expanding Medicaid 100 percent for the first three years states participate, after which federal dollars slightly curtail over the next decade. Even at the lowest point of federal funding, states would only be liable for 10 percent of the cost of the expansion in their state, but still reap 100 percent of the benefits of not having a populace burdened by the under-insured.

To add to Sharone’s woes, she was also just notified that Congress has made significant cuts to Food Stamps, which is going to make it even harder for her to put food on the table—another instance of the Right-Wing’s assault on the poor under the pretext of “fiscal responsibility” and “small government.”

“I’m just not sure what I’m going to do next,” says Sharone. Even with all the hardship she’s facing, still manages to keep a sense of humor and giggle as she asks, “Think there’s any chance Congress will pass a single-payer system soon?”

Sharone’s story is only one of 5 million from across the country. From the 500,000 people being denied coverage in North Carolina, to the 133,000 in Utah, to the 40,000 in Alaska, the stories of the working poor being denied healthcare are everywhere. Why don’t we hear about them on the nightly news?