• Liberalia and Teapartystan divide over the ACA

    The US has split over whether to implement the Medicaid expansion in the Affordable Care Act.


    The dark blue states are expanding Medicaid. Let’s imagine they were a country — call it Liberalia. Liberalia had an estimated 146 million people in 2012. The remaining states have either rejected the expansion or are still debating it. Call them Teapartystan, a nation of 168 million people.

    Liberalians live longer than Teapartystanis.


    Life expectancy of birth summarizes manifold health differences across regions. The average life expectancy in Liberalia is 79.9 years, which is the life expectancy of Great Britain and Belgium. Compare this to 78.1 years in Teapartystan, the life expectancy of Cuba, the Czech Republic, and Barbados. Does this 1.8 year difference seem small? Sum this difference across all Teapartystanis and you get about 300 million life-years lost.

    The eight states with the highest life expectancy are Liberalian: New Jersey, Massachusetts, New York, Vermont, California, Connecticut, Minnesota, and Hawaii (which would be on the map if my programming skills were better…). Four of the states with the lowest life expectancy are Teapartystani: Mississippi, Alabama, Louisiana, and Oklahoma (the fifth, West Virginia, is Liberalian). Life expectancy ranges widely across the states. Minnesota and Hawaii have the life expectancy of Norway or the Netherlands. Mississippi and Alabama have the life expectancy of Mexico, Vietnam, or Venezuela.

    Liberalians earn more than Teapartystanis.


    Liberalian households earned an average of $55,756 in 2011 compared to $47,189 in Teapartystan. Liberalian households were 18% richer than Teapartystanis.

    By their lights, Teapartystanis can acknowledge these facts and rationally reject the expansion of Medicaid. That would make sense if they believed that expanding Medicaid would harm their population’s health or make it poorer.

    This bewilders Liberalians. They believe that there is no credible evidence that Medicaid is worse for health than being uninsured. Moreover, Teapartystan suffers more heart disease, more strokes, more you-name-its. Expanding Medicaid wouldn’t fix this. But a stroke victim needs care and the Medicaid expansion would transfer funds for that care from richer Liberalians to poorer Teapartystanis. How does Teapartystan come out ahead by rejecting this deal? Ezra Klein:

    In the states, Republican governors are saying no to billions of dollars in Medicaid money (and, in a number of cases where they said “yes,” their even-more conservative legislatures have said “no” on their behalf). That cuts them off from much-needed funds and cuts their poorest constituents off from free heath insurance. Moreover, it means their safety-net hospitals lose money they were relying on to survive — forcing devastating cuts to care. The result is a poorer state, worse-off residents and a health system under terrible financial stress.


    • Is it possible that they reject these federal to state transfers because they object to federal taxpayers financing wealth transfers to states?

      Perhaps they think it inappropriate take money from some states and give it to others? Perhaps they think this is wrong, even when they would be the recipient states?

      Of course, it could be concerns that they would accept the entire deal, more money, for a while, from the federal government, and an ongoing expanded state obligation.

      The behavior ceases to be puzzling at all if you understand the Tea Party view that government should be limited. Thus, a Tea Party supporters reject the idea that expansion of federal power and influence on the state economy is desirable as long as they can pretend that someone else it paying for it.

      • dbh,
        I gave one explanation whereby conservatives could, by their lights, reject the Medicaid in a rational and principled way. I am sure there are others.

        I wonder, though, about whether it makes sense to explain the rejection in terms of a rejection of state-to-state transfers. Clearly, conservatives affirm limited government principles. But look at the recent farm bill passed by the house. It eliminated food stamps, but kept the agricultural subsidies. These subsidies are wealth transfers from urban states to rural states. Perhaps tea partiers opposed them, but Republican House members supported them.

    • Let’s see, Liberalia would be the regime that places 146 million people under the thumb of a central authority (for just about everything), yet Mr. Gardner compares red states to authoritarian regimes in central Asia? Am I missing something?

      Mr. Gardner also conveniently ignores Liberalia’s significant financial problems (see e.g., California, Illinois, New York, Detroit, Greece, Italy, Spain, etc.). And this kind of defense of blue state big government has been done before – I think originally by Dostoyevsky’s Grand Inquisitor.

      • Nah, California has got its budget problems well in hand. We got rid of the Republican actor who was going to eliminate waste-fraud-and-abuse and put an experienced guy in his place. We also got rid of gerrymandered legislative districts and further diminished the rump Republican contingent who were managing to block sensible financial legislation. We voted to raise taxes on everybody, rich and poor, not just Phil “Wah-wah” Mickelson (you just heard about the tiny increase in taxes on the very wealthy on Fox, but actually we raised taxes a little bit on everybody). We also ended the three strikes rule which will help us get our prison costs under control. There’s still room for improvement, but we’re going in the right direction. Honestly, if you get your information from Fox, you aren’t getting good information.

      • Alsan,
        I think the comparison that you are talking about is the comparison of Mississippi and Alabama to Vietnam?

        What I think you are missing, since you asked, is that I compared their life expectancies at birth. I didn’t compare their political systems.

    • If the goal of Republican governors is to make their state less hospitable to poor people and minorities, then they are ahead by rejecting Medicaid.

      Also, many states have the following fear: once they let in new Medicaid beneficiaries, for now with federal dollars,then sooner or later they will have to cover millions of beneficiaries who are eligible under current law but not signed up.

      These current-law beneficiaries will NOT be covered by all federal dollars.

    • Constructing the division between “Liberalia” and “Teapartystan” at the state level seems quite arbitrary. Take a political map of just about any state, and you’ll find significant heterogeneity all the way down to the zip-code level. Ditto for any health metric of your choosing.

      I can understand why one might want to frame the analysis in terms of states, because then one can proceed to reason that all of the characteristics of the population within those boundaries have their origin in, and can be explained by, the set of policies constructed in state capitols.

      Clearly that’s not the case. Take a look at Massachusetts. How can the same wise and benevolent policies that have elevated the populace and economy of Boston to such heights simultaneously account for Worcester and Springfield? For that matter, how does the policy environment in MA simultaneously suffice to explain Brookline and Dorchester? How does a city like Austin, Texas fit into this analysis? Can this account for the fact that aggregate measures of health, wealth, and longevity vary more within states than between states?

      • JayB,
        Your point about within-state heterogeneity is well-taken. The differences in health and health care within states are real and very important. In particular, I am confident that you are right in saying that the variation within states is greater than the variation between states. If what you are saying is that it is essential for state governments to understand this and to develop interventions to improve the population health of their poorest communities, I am completely with you.

        However, in this case it makes sense to make state to state comparisons because that is the level at which decisions about Medicaid are made. It isn’t arbitrary, because if the Ohio legislature rejects the Medicaid expansion, it rejects it for the whole state.

        Moreover, just because the within-state variation is greater, that doesn’t mean that between-state variation is unimportant. Minnesotans and Hawaiians live about 6 years longer than Mississippians and Alabamans. That is a tragedy for the latter.

    • Note to dbh —

      Tea Partiers somehow never protest the enormous transfers of wealth from the nation over to states in defense spending, homeland security spending, etc.

      Chris Christie made this point when he noted that Rand Paul’s state of Kentucky collects $1.50 from the federal government for every $1.00 that its residents pay in taxes.

      The Tea Party makes a definite distinction between “good welfare” like Medicare and Social Security and Defense spending, vs. “bad welfare” like Medicaid and Aid to Dependent Children (or whatever that is now called.)

      A cynic might notice the complexions of those who predominantly receive each type of welfare.

    • Bob H,

      “Tea Partiers somehow never protest the enormous transfers of wealth from the nation over to states in defense spending, homeland security spending, etc.”

      We must see different Tea Partiers. I am not a Tea Party supporter, but I do enjoy devil’s advocacy when I find myself echo chambers.

      I have heard lots of self-described Tea Party people complaining even more bitterly than I do about the gross, obscene, nearly unimaginable scale of our defense budget. As we have seen in the NSA episode, we don’t actually know the amount of spending on homeland security. Rand Paul proposed dramatic cuts to the Department of Homeland Security. The Tea Party is not a unified national group, but a banner to which people of more or less similar views can rally. So there is not a single source that will tell you what “The Tea Party” proposes for military spending. However, it is easy to find self appointed Tea Party spokespeople advocating major cuts in the DOD budget.

      Complexions of those who receive different types of transfer payments? I don’t follow. As far as I know, the single largest racial group on Medicaid is white. The second largest group is “Hispanic”, which includes people who are white and those who are not.


      The separation by state appears to be in part for rhetorical effect, and in part to reflect that policies on things like Medicaid, state exchanges, and other social welfare spending are decided at the state level.

    • The struggle by northern liberals to “federalize” welfare has been going on for at least 80 years. In northern eyes, states’ rights are seen as an ugly throwback to the days of legalized lynching.

      In the Civil Rights era, the imposition of federal standards on reluctant states was accomplished through the courts and occasionally with federal troops.

      Today, the imposition of federal standards depends on electoral majorties — which makes the voting rights laws so signficant.

      But even with vote suppression, something is askew in the most conservative states.

      If Medicaid was absolutely available to everyone up to 130% of poverty, then in a state like Lousiana at least 25% of the adult population would be on Medicaid.

      One would think that 25% of any populace could get what it wants electorally. But that does not happen, for a variety of reasons.

    • West Virginia is Liberalia?? As with Kentucky, it’s more likely to be a case of FreeMoneyistan.