Why (some) governors oppose the Medicaid expansion

There’s a new Perspectives piece over at NEJM that analyzes statements by governors wo support or oppose the Medicaid expansion. Here are rationales behind opposition:

Among governors opposed to expanding Medicaid, statements about affordability and impact on state budgets were nearly universal (92%). Cost concerns fell into several categories. Some pointed to the so-called woodwork effect, in which the ACA could draw previously eligible but unenrolled persons into Medicaid, at greater cost to the state. More than half the governors opposing expansion predicted that the federal government would renege on the generous terms of the ACA and scale back its share of Medicaid spending. Newly elected Governor Mike Pence (R-IN) compared the expansion to “the classic gift of a baby elephant. . . . The federal government says, `We’ll pay for all the hay — for the first few years.’”

Beyond cost, governors expressed concern about the lack of state flexibility or their belief that Medicaid may foster dependence among beneficiaries. For instance, Dennis Daugaard (R-SD) declared that “able-bodied adults should be self-reliant” — in contrast to children or people with disabilities, the traditional Medicaid beneficiaries. Others argued that Medicaid itself is the problem, calling it a “broken program” that provides poor care. Most vividly, Rick Perry (R-TX) said that adding uninsured Texans to Medicaid is “not unlike adding a thousand people to the Titanic.”

None of this should be new to readers of the blog, but unfortunately, not everyone in the country is yet a regular reader.

I understand the “woodwork effect”, but that will happen with or without the expansion. Fear of the individual mandate will drive people (even if they were exempt from it) to get insurance. The increased public perception of the availability of insurance will also drive those who are eligible for Medicaid to claim it. Therefore, I’m not sure that denying the expansion will protect states from this issue.

Others fear that the government will renege on its obligations. I guess they could? But they could do that on any program, including traditional Medicaid. Plus, they could put in a protection against that, as Gov. Brewer recommends.

The rest is harder to entertain. Medicaid works. There’s no magical innovation just waiting to be enacted.

I still think it’s going to be harder and harder for those opposed to keep this up as time goes on.


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