Point/counter-point: Should states expand their Medicaid programs?

Aaron and I take up the pro-Medicaid expansion side of the latest point/counter-point in the Journal of Health Politics, Policy and Law. Joe Antos represents the con side. Harold Pollack introduces the debate. I was told that all papers are would be ungated in advance of their appearance in print. Alas, they are not, but I’m working on it. Indeed they are ungated!

In case you don’t know, the way this worked is that Aaron and I wrote our piece, then Antos got to read and react to it. So, though Antos had the opportunity to respond to us directly in print, we did not get to respond to him. So, I’ll make a few counter-counter-points here. You may wish to read the papers first. In doing so, I encourage you to note (even write down) your prior view on Medicaid expansion. Then see if either we or Antos moved your view. Let us know in the comments along with anything you think was left out of the debate or that any of us got wrong.

First, here are some areas in which we all (mostly) agree:

  • State elected officials are politically constrained in their choices. Antos is quite explicit on this (“If you choose the latter [Medicaid expansion in your state] you stand a good chance of being thrown out of office the next election.”) We discuss politics at the end of our paper, concluding that it is not our job to look after the political fortunes of state officials. That they will (or won’t) expand Medicaid and that they should (or should not) are separate matters.
  • Expanding Medicaid is not free for the states. Reading Antos’s paper you might think we dispute that, but we don’t.
  • Antos makes a direct appeal to the virtue of choice. We don’t take that up in our paper, but we do not dispute that there is value in choice.
  • The Medicaid expansion was a lower cost means of increasing coverage. Antos and we acknowledge that private coverage costs more, as would increasing Medicaid payment rates to providers.
  • States may be able to use the Medicaid expansion as a bargaining chip, to extract favorable waivers from the Center for Medicare and Medicaid Services (CMS). We wrote that, and Antos seems to agree. We also probably all agree that this is among the most important unsettled areas to watch in terms of health policy.

Here are some things on which we (may) disagree:

  • We do not agree with Antos that no coverage can be better than some coverage. To be sure, sometimes medical care can be harmful to health. But far more often it isn’t. As I’ve written before, half of recent longevity gains are due to medical care. Insurance is key to access to care (PDF), even insurance with constrained provider choices like Medicaid. (Private coverage is also highly constrained.) Antos cites Bokus et al. (2009) and provides some access statistics from that work. He does not indicate the degree of access problems for the uninsured, nor do Bokus et al. Oregon’s Medicaid randomized experiment — the strongest evidence we have about the effects of the program — shows that the uninsured have far worse access to care than do Medicaid enrollees.
  • Though greater rates of insurance will increase demand for care and likely increase waiting times for certain services in certain areas, we wonder if those unable to afford insurance today should wait for us to solve the workforce (and cost control) problems? (We don’t think so.) If they should be made to wait, how long?
  • We don’t agree that health care coverage should be secondary to addressing other social problems, like inability to afford food or providing a good education. We think health care, food, and education are all worthy of our attention and, yes, government spending (redistribution). Further, we don’t think that any of these are at odds with promoting a “sound economy and a brighter future” (per Antos’s final paragraph). They are integral to it. Healthy, sufficiently fed, well-educated people are better workers and more voracious consumers.

I’ll leave you with one final point: I remain puzzled why those who find the ACA too expensive also seem to advocate for more expensive alternatives (more choice through private coverage, say). I’m perfectly comfortable with an all-private health insurance system, one with more choice for all, provided everyone has access to affordable coverage. But I own the fact that it will be more expensive than the one we have. I also am far from convinced that going all-private is the only way to improve our health system.


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