When thinking about the decision before state lawmakers over whether to take additional federal dollars to expand Medicaid, the proverb “Let no good deed go unpunished” comes to mind.
The Affordable Care Act originally gave states a Hobson’s choice: Expand a bad, expensive program or lose all federal funding for it.
The U.S. Supreme Court’s 2012 decision largely upholding the law gave the plaintiffs one small victory, ruling that the federal government cannot coerce states to expand their Medicaid rolls by threatening to withdraw funds if they opt out.
But the victory for federalism left states with difficult choices on how to help the millions of people left in the “coverage gap.”
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For “expansionists,” who believe that Medicaid may be the silver bullet for solving the riddle of universal coverage, the decision is nothing short of a moral imperative.
For expansion opponents, who see turning down federal dollars for a bad program ( called a “caste system” by Sen. Ron Wyden, D-Ore.) as a prudent financial decision that avoids pickpocketing 49 other states, dumping people into Medicaid poses serious problems.
If Texas took the expansion, people below 138 percent of the federal poverty level would be effectively forced into the program. This includes many of the 2.3 million Texans between 100 and 138 percent of the poverty level who can now receive subsidies to buy a plan of their choosing in the private insurance market.
How is Medicaid a better option for them?
Adding more people to the Medicaid rolls guarantees neither access nor improved health.
Stuffing more patients into a bloated program accepted by fewer and fewer providers will increase wait times, making preventive care even less likely.
An analysis of Oregon’s experience found Medicaid did not limit, but increased, use of emergency rooms, which ACA proponents finger as a primary driver of healthcare costs. Neither did Medicaid result in substantially better health outcomes for people who have it compared with those who do not.
In a forthcoming book published by the Mercatus Center at George Mason University, Robert Graboyes examines the growing bounty of evidence suggesting that “Medicaid badly fails the enrollees it is designed to help … [and] falls into the same category as inner-city public schools and government-run housing projects — hugely expensive social engineering initiatives that often fail their recipients.”
So the “good deed” of Medicaid expansion has undone itself.
But Medicaid’s failure does not give those who oppose expansion an excuse to sit idly by.
Scott Walker, Wisconsin’s Teflon governor, offers one solution that might become a model for other states. Wisconsin, which caps the number of people who can enroll in Medicaid, bumped about 77,000 people with incomes above the federal poverty line from the rolls, making room for 83,000 poor, childless adults previously not covered.
Those dropped from Medicaid were not left in an insurance dead zone; they will be eligible for private, subsidized coverage of their own choosing in the exchange.
Paying even a nominal cost for an insurance premium gives these people something that many Medicaid proponents don’t want them to have — skin in the game.
Wisconsin’s Medicaid system is certainly different than those in other states. But it does not mean that a variation on this theme is out of the realm of possibility elsewhere.
As with almost every part of the healthcare law, this dilemma is complex and requires thoughtful leaders who take the mantra “states are the laboratories of democracy” to heart.
Can Texas be one of those states?
As Graboyes writes: “One can strongly support the idea of a social safety net without assuming that the present-day incarnation of Medicaid is the only option.”
The fight can no longer be just about opposing Obamacare: Policymakers need to offer viable alternatives.
One conservative state leader has found a workable solution. Texas leaders need to do the same.