• All Medicaid expansion politics is local

    In this morning’s Wonkbook, Ezra Klein suggests that the Medicaid eligible in states that don’t expand the program might turn out to be a meaningful political force.

    It’s a truism of health-care politics that the uninsured are impossible to organize. But Obamacare creates an extraordinarily unusual situation. The Affordable Care Act will implemented in states that reject Medicaid. There will be huge mobilization efforts in those states, too, as well as lots of press coverage of the new law. The campaign to tell people making between 133 and 400 percent of poverty that they can get some help buying insurance will catch quite a few people making less than that in its net. And then those people will be told that they would get health insurance entirely for free but for an act of their governor and/or state legislature.

    I’d keep an eye on how provider associations — particularly hospitals — respond. They’re the groups that both have something to lose here and are organized to do something about it. I’d keep half of my second eye on insurers. Even though Medicaid can be expanded as a public program, it could also be expanded in a way that throws more business toward insurance companies (e.g., Arkansas’s private option).

    If insurers and providers put their lobbying muscle and money where their interests are, they might swing none too few local elections in a way that favors expansion. That’s when the Medicaid dam may break. The next set of state and local election cycles could be very interesting.


    • I was talking about the Medicaid expansion with a hospital association exec in a state that’s not taking the expansion and asked what the governor thought about what he was hearing from hospital execs. “He doesn’t care,” was the response. They could go broke, he just didn’t care. At least that’s consistent with not caring about the uninsured.

    • To my surprise, I’ve encountered the same thing as SteveH in my reporting on this subject. The hospital lobby hasn’t been able to break through the ideological noise about Obamacare in the way I thought they might.

      Perhaps I should’ve expected this. After all, the alignment of the national hospital lobby (not to mention other health care interests like PhRMA) in favor of the ACA did nothing to sway Republicans in Congress or conservatives at large.

      What may shift this dynamic would be evidence of real harm to hospitals at the state level over the coming years. Of course, the Obama administration’s decision initially to shield hospitals in non-Medicaid-expanding states from DSH cuts could make this less likely by reducing the potential damage.

      • Thanks for your response Jeffrey. I wonder whether the administration’s decision to make the DSH cuts less painful (at least initially) is politically stupid. After all, it lessens the hospitals incentive to put pressure on their state governments. On the other hand, it makes the Obama administration look like it’s not trying to punish states that haven’t gone along with expansion while sparing providers the brunt of the state’s bad decision.

    • We are not in normal political times and the types of political coalitions that used to have sway don’t necessarily work anymore. In Kansas, for example, nearly every group that would normally have some influence on such a decision – health care providers, insurers, agents, many business organizations, foundations, etc.- lobbied for a state insurance exchange. It made no difference.

      The Medicaid expansion debate in the Kansas legislature has hardly focused on health and health care and instead revolved around expansionary monetary policy and deficits at the federal level.

      Toto, I don’t think we’re in Kansas anymore . . .