A Deal Too Good to Turn Down, Unless It’s Medicaid

If a C.E.O. rejected a deal offering an infinite rate of return, shareholders would probably sue. Not so when the C.E.O. is a governor and the deal involves Medicaid.

Comments: 94

  1. The ignorance of the people who elect officials who consistently take actions that are obviously not in their self interest is staggering. Here is a program that provides major assistance in their health care and lowers their burdensome state taxes and they put in officals who say a resounding no. Any rational human being would jump at the chance to accept such a gift. As far as I am concerned let them wallow in their stupidity.

  2. Unfortunately (in those states) those of us who didn't vote for the conservative winning candidate (some 50% of us) are punished. It seems that there are a lot of mean-spirited voters out there and tremendous lack of compassion for fellow human beings. When I asked people in Florida why they would vote for a candidate who is against universal health-care/medicaid, they universally tell me "why should I have to pay for someone else?" When I ask them about medicare (which they all have), they tell me "it's a wonderful thing". So what I see is if it's for ME it's good, if it's for YOU I'm not paying.

  3. "... let them wallow in their stupidity."

    So, you want "them" to suffer because they are not as smart as you?

  4. Mr. Lausten, would agree but for the steady diet of lies these politicians feed the public. It goes beyond posturing and politicking -- they LIE, shamelessly, intentionally and repeatedly. And the media (for which I worked as a newspaper reporter for many years) has become too weak and lazy to call a lie a lie. Reporters/editors/publishers feel compelled to give equal weight and space to political positions in the guise of "fairness." If they catch a politician in a lie, they should have the spine to say so, over and over again until the misinformation is wiped from the minds of the voters. It's unfair to call voters stupid if the problems is that they have been systematically misinformed. How many people still don't believe Obama is an American citizen?

  5. Yes, exactly. Strong political—or perhaps philosophical—principles trump reality in these states dominated by pathological austerity [for the poor] and rigid antigovernment attitudes. The candid statements of Mr Perry only serve to highlight how foolish they are. Yet, Mr Rheinhardt's confidence of change for the better must be hedged by the lack of action so far by these putative "powerful lobbies of doctors and hospitals." The question to consider is, what are they waiting for?

  6. @ E.T. Bass
    All of your links are very dated, with the earliest being 2011 and the oldest 2006, long before the implementation of Obamacare. Wikipedia is not a reference. However, in reading the other two, it is important to note that the 2011 article, lack of access to specialists, does not seem to have to come to pass in states that expanded (aside from some overhyped stores on cable news) and the article on Oregon from 2006 was written as a lessons learned for the upcoming implementation of Romneycare in Massachusetts, which does not seem to be having any major documented troubles with access.

  7. B, are you offering to bail out others if their Medicaid plans cause financial problems?

    Because if you are not -- your words, and Uwe's, are empty.

    Actions speak louder than words. After "you can keep your doctor" was repeated on TV 213 times.

  8. A new study just published in the Journal of Clinical Oncology concluded, “Among patients with the 10 most deadly cancers, those with Medicaid coverage or without insurance were more likely to present with advanced disease, were less likely to receive cancer-directed surgery and/or radiation therapy, and experienced worse survival.” (Though keep in mind that low-income populations face many other barriers to care than just the inadequacies of their insurance coverage.)

    It would be easier to understand states rejecting the expansion of Medicaid if they were to support an alternative that was a distinct improvement over this chronically underfunded welfare program that falls so short of reform goals. An improved version of Medicare that eliminated financial barriers and covered everyone would have been a much better choice.

    What is so astonishing is that the rejection was not based on altruism, since no alternative was offered, rather it was based ideological rejection of principles of social justice, specifically health care justice. The United States seems to be unique in being dominated by voters who reject politicians that support egalitarianism - American exceptionalism that the people of other nations cannot understand.

  9. I don't think there's really anything so mysterious about this--it comes under the heading of 'cutting off your nose to spite your face'--those rejecting Medicaid expansion see this as a way to figuratively spit in Pres. Obama's face, and they simply do not care who gets hurt in the process, especially since most of the 'hurt' is meted out to people who don't matter in their scheme of things.

    Perhaps Gov. Perry hopes those needing care will simply take themselves and their poverty to another state so he'd be rid of them, or maybe he has even darker hopes for their prospects. Any politician who ignores the well-being of a quarter of his constituents (and also puts the health of the remaining three-quarters at risk by doing so) clearly has other things on his mind than doing the best that he can for his state.

  10. I understand the puzzlement of the economist. Let me shed some light from the perspective of one of the states who rejected the expansion of Medicaid. Maine's legislature voted for the expansion, and Gov. Paul LePage vetoed it.

    In his words, “The expansion offered through Obamacare would have a disastrous impact on Maine’s budget, as well as those truly needy individuals, our disabled and elderly, who rely today on the scarce resources in our program. Maine has been down this road before, and we must learn from previous experience.”

    There are only two explanations for his reasoning:

    1) He is an idiot and actually believes that money from the federal government will bankrupt Maine's Medicaid program, which was so clearly refuted in this article. Or...
    2) He completely lacks empathy for the tens of thousands of Mainers -- many of them children -- who cannot afford healthcare. He is happy to see them suffer and die prematurely.

    Personally, I think it's both in equal measure. Having listened to him bloviate for the past four years, he has proven himself to be both a bully and a moron. (In arguing against a ban on BPA in plastic because the toxic effects are not that serious, he said, ‘worst case is some women may have little beards.’ I kid you not.)

    As for how he was elected -- he barely won the majority of votes in a three-way race. Unfortunately, he is up for re-election again, and it is once again a three-way race. If he's elected again we are doomed.

  11. "(...worst case is some women may have little beards.’ I kid you not.)"

    This surprises me because I've been in Maine and the people I met there are the best. Any politician who said that in Minnesota would not get ten votes.

  12. I suspect the 'thinking' by these Governors is quite simple:

    1) The governors honestly don't care about the health of the poor. The poor are also highly unlikely to vote for these governors' party regardless.

    2) Providing health care for the poor would seem like a victory for the Democrats and Obama, and that must be avoided even at the cost of human life and in the face of economic reality.

    It is difficult to reconcile their actions with any other position.

  13. "A deal too good to turn down” often leaves one empty pocketed when the scammer is gone. That is a problem with superficial examinations of the true costs of things. The real costs are unknown. The state of Florida probably made the right decision both intellectually and financially.

    Do federal dollars grow on trees? No. They are involuntarily extracted from the taxpayer’s pockets, so when one says that the deal is a good one without considering the actual taxpayer costs one is being a bit disingenuous on the intellectual side of the coin. If a thief steals money and gives some back that money is still stolen money.

    Financial side: One credible estimate of general revenue increase for the state of Florida demonstrates the deal to be a bad one. (Pre ACA) 2008: $6Billion; expanded program 2030: $24 Billion. Forgetting about the uncertainty of how long the government will subsidize 90% for these new patients many of the new patients enrolling would not be covered by this deal and Florida would not be paid the 90% for them. Many patients would, however, be covered 60% in the federal exchanges. We also have to remember that this new program displaces people from private insurance and places them in the Medicaid program. That means that formerly private entities were paying for the insurance and that bill has been transferred to government agencies.

    I won’t even discuss the natural experiment of the Oregon Study that questions the benefits of Medicaid.

  14. "this new program displaces people from private insurance and places them in the Medicaid program. That means that formerly private entities were paying for the insurance and that bill has been transferred to government agencies."

    ... so those who earn less than the federal poverty level were spending their meager earnings on private health insurance ( @ several hundred $$ a month) instead of food and shelter? where do you get that idea?

  15. No, the 100 to 138% of poverty level. A good number of them had jobs that provided much better insurance for them which the employer was paying for.

  16. Well that's fine and while I don't agree with your comment at all, it's certainly okay with me.

    And for those of us who live in states with both a brain and a heart that did embrace the expansion of Medicaid, it's only right that we express our appreciation to Florida taxpayers for helping to pay for the health coverage of low-income residents in states such as Washington.

  17. Perhaps the providers are not putting political pressure on states because they prefer to charge the uninsured retail. If they can bring in only a fraction of billings at inflated prices reserved just for the uninsured, through aggressive collections, they might make more profit on this segment than through Medicaid rates.

    Once tax write offs for losses and government subsidies are considered, as well as the very expensive ER delivered care, there may be more revenue and profit in the status quo. After all, that is what health care is largely all about in America.

  18. I think your observation is accurate if you substitute "hospitals" for "providers." If a simple laceration is 1000$ why accept an in network Medicaid rate?

  19. The uninsured in Florida and Texas can just continue to go to the emergency room for routine medical care, as they have in the past.

    There a simple "office visit" gets billed to somebody at $900. An incredible bargain. And who's better equipped to handle a complex pediatric case than a Surgeon training to treat gun shot wounds?

  20. I like the argument but hate this analogy.

    In Uwe's analogy, the company goes out and sells product and then has to pay back 10% to the original patent holders. Gone unmentioned there's like some distribution and administration costs, but as long as those are <89% the product is profitable and efficiency gains only reap larger profit.

    But that doesn't describe the situation. First off, the states would be cash-flow negative. Instead of reaping in revenues and then settling up, they actually shell out to cover Medicaid and then get reimbursed. Given the high and volatile costs in health care, combined with a volatile and unreliable federal government, I can understand some reluctance.

    Add to that, the states don't "make" the remaining 90%, they merely get to spend it on healthcare. They are still adding a budget item for their share of 10%. To offset it and be "profitable", they need to reap in extra revenue somewhere (taxes?). I agree with Uwe that the extra 90% entering the system should be pretty powerful to collect the original 10% back in taxes.

    But, it's also easy to see that a lot of health care entities are non-profits or operate at a loss (ie fewer taxes to collect) and a lot of medical spend is on devices and pharma (ie companies that are not necessarily in-state, and so are at best paying sales tax, although this sector is probably only 15-20% of health spend).

  21. For Republican states, the answer is simple. Nothing, nothing will be willingly done to help the bottom 50% of the population, no matter how much money is offered. The conservative ideal is to eliminate those people entirely, and as quickly as possible. Wonder who will pay those taxes when they're gone. (I like the analogy to the Titanic. Just let 'em drown. Don't even try to save 'em. And, don't put more lifeboats on the next ship.)

  22. i think the Republican governors are thinking long term.

    This new entitlement is fine until the US government stops paying for it as they have already truthfully stated.

    What is going to happen when Federal government stops paying for this?

    We will become Illinois- just joking of course-

  23. @Steve - you miss the point that it's not ' spending ', it's investment that creates jobs in the healthcare field, and helps keep the doors of small hospitals open. It's obscene for Texas to pass up $79 Billion$ from DC over the next decade:


    that would help create infrastructure, jobs, and increase the tax base for the day sometime in the future when DC only picked up 90% of the cost.

    Whoever heard of a Texas governor leaving $79 Billion$ laying on the table, especially when it's money Texans have already sent to DC, and other states will be taking their share back to invest in their state healthcare infrastructures ?

    Whoever heard of a Texas governor deliberately giving a lead to other states on such an issue ?

  24. Oh !! It's not spending. It's an "investment" ! Where have I heard this before ? Oh yeah, it's from the $831 bn Stimulus from 2009. Now what did that get us again ?

  25. I'm not persuaded that Gov. Rick Scott of Florida lifted so much as a finger to get the Florida legislature (or more specifically, House speaker Will Weatherford) to accept Medicaid expansion. The state Senate would likely have gone along. Weatherford will be gone next year, so there may be hope, even with a re-elected Scott.

  26. You are exactly right according to what I have read. Apparently Governor Scott "supported" Medicaid expansion long enough to tell voters he was for it. But he did nothing, nothing, to try to convince the legislature to go along with it. He did not try AT ALL. You can check this out by looking at articles written in the Florida newspapers online. So it mystifies me that this economist says Scott "could not persuade his legislature to go along," because he never TRIED to persuade them at all!

  27. In addition to the reasons Prof. Reinhardt cites, the board and CEO would be thrown out for willfully, purposely handing over to states who accepted the medicaid expansion a distinct competitive advantage when it comes to attracting companies looking to move their H.Q., etc.

  28. I've lived through Claude Kirk as gov. and believe me, he was a sweetheart compared to Rick Scott. Scott is in the pocket of Big Sugar and then blathers about how he's an environmentalist after he appoints one of their execs. to an oversight comm. on the enviromnet. Hope we don't have him for another term.

  29. Yes, the red states are acting stupidly. That's what they do.

    However, it's nice to have *something* to balance the massive, continuous transfer of wealth from blue states to red states. We pave their roads and build their schools. A few dollars to cover our medical bills won't go amiss.

  30. Dr. Reinhardt,

    Your article has raised an interesting question.

    When people don't act in their self-interests it raises serious questions about the culture that they are in. The people in Texas, Florida and the other states who are rejecting this huge gift horse provided by the taxpayers including their own taxes is an aberration in what would be expected in the behavior science and is worthy of further study.

    I suggest that this aberration should be studied by polling the people of the states to try and get a better handle of why they have rejected caring for medicaid candidates. I suspect that they don't know the facts & have somehow been persuaded that if they treat their medicaid candidates the way they have, they will somehow be better off.

    So I think we should explore what they know & what persuaded them to think that it would be better if we let medicaid candidates seek healthcare by their own devices.

    What people believe is mysterious & it requires careful careful observation to get to their true beliefs. As an economist you already know that reality is independent of human representation. Our beliefs are formed from experiences & our instincts. Maybe this article will persuade the sociology community to organize a study to share with us how the Medicaid rejectors came to their position.

    It occurs to me that they may have been persuaded by an organized campaign of distortions and lies. It has happened before. Our media spins illusions very easily.

  31. Republicans often harp how government is the problem, or such-and-such federal system is broken, but the primary reason that these system would fail would be because Republicans intentionally break them. In the same way, government incompetence is often the result of Republicans impeding government work...

  32. Prof Reinhardt, I think your analogy sheds more light on your wonderings than you may realize. Shareholders are rarely able to throw out corporate management or even achieve significant change in corporate policy. Corporate management controls what issues are brought forward for votes by shareholders, they control the wording and timing of votes and management often controls or can count on a very large share of votes in favor of their position. They also direct the corporation's legal staff and they staff and often sit on corporate committees that establish policies that affect shareholders' rights and opportunities for input.
    You used Texas as an example. The State has a long history of preventing the poor and minorities from voting. The current governor and legislature have passed significant voter suppression laws recently. The State is run by commissions controlled by Rick Perry, much like corporations have committees controlled by the COE and others on the senior management.
    team. So, I wouldn't expect a voter revolution at the polls anytime soon.

  33. So. I guess all of you guys would immediately sign on to the lucrative gas leases many people in my neighborhood have gotten since the fracking boom began.
    After all, only money is the true measure of value. Not principles, not evaluation of how trustworthy a partner may be or any potential long-term problem.
    If the big guy has plenty of money and he is offering you some, just take it and shut up.

  34. It's not just "money" but money to save lives and make life better for millions of people and families, and also provides many good jobs.

  35. With all due respect to Dr. Reinhardt, this is not "straight economic theory". It's a bit like the mafia telling you what a great deal you are getting that by making a donation, you get free protection services. What a deal !

    This is not a free lunch. It is coercion by Obama. And for those who read the Supreme Court decision on Obamacare, "such a threat is coercive and that the states cannot be penalized for not expanding their Medicaid coverage after receiving funds. And it does so in the context of Medicaid, which Congress created and can alter, amend or abolish at any time..."

    The States in question are simply opting not to be on the hook for an estimated 4.7 million Medicaid enrollees. Keep in mind that the States already spend 24% of their budgets on Medicaid - http://www.nytimes.com/2011/12/14/us/in-downturn-medicaid-takes-up-more-...

    Now the reader may disagree with this choice and perhaps believe that health care is a right. And they are entitled to this opinion as are the States that chose to expand Medicaid. But they ought to equally respect the choice of others who do not want to expand government in this way even this makes people like Dr. Reinhardt "puzzled".

  36. Interesting - most of the red states are net recipients of federal aid. If they are so against government help, why don't they turn down the subsidies that the blue states are giving them? Is it maybe because a black president didn't give them to those states?
    Health care is a right. Why won't Texas provide its citizens with health care?

  37. It's still difficult to ignore that all the states are republican.

  38. Sally, they are not against federal aid. They are against using gov't money to help poor people.

  39. Ironic, since most of these states are already net tax parasites. Who ever heard of a leech passing up a meal?

  40. How are we gonna privatize everything if the government keeps getting in the way? I mean, why should everyone in the world's wealthiest nation at the height of civilization have equal access to services when a few could be making more money by selling these prized services to the highest bidders? Don't forget that while all men are created equal, some are more equal than others.

  41. Governor Rick Scott was against the Medicaid expansion until polls showed it would hurt his re-election campaign. Scott also single handedly refused $2.4 billion for building high speed rail between Tampa and Orlando. The $2.4 billion for the project was to come from stimulus money and wasn't estimated at the time to cost Florida taxpayers a penny. (Scott whined about potential cost overruns and future maintenance.)

    This year, high speed rail skeptic Governor Scott backed state funding for a private high speed rail company with ties to his chief of staff.

    Shocker, right?



  42. When Scott walker came to office Wisc was on the verge of installing a higher speed rail that would connect Madison, Milwaukee and Chicago. Federal money was paying for the bulk of it. The rail was never built because Walker scrapped the plan, calling it a boondoggle that would be expensive to operate. No new jobs, no rail, and he made the train company pull its business (more job loss), but not before they had built cars for the line. After all the planning for nothing, Wisconsin is now on the hook for some $100million for broken contracts and canceled orders. Meanwhile, the train company moved to another state and will end up connecting Chicago to the twin cities, bypassing Wisconsin altogether.

  43. Why should there be any doubt that these states like FL and TX who have rejected the Federal Affordable Health Care deal are conservative republican controlled , where the people who will gain are poor and minorities . The Status quo is the GOP would let them be sacrificed with coercion, reckless abandon, impunity and no qualms. In fact these folks number some 50 million plus. The impetus is they will never get a chance to vote or be counted. Disenfranchisement is par for course.

  44. One might read this article and wonder why the Republican-led legislatures of 24 states have rejected the federal money that accompanies the expansion of Medicaid eligibility. It is not, as the author implies, irrational, nor is it entirely a matter of principle. As a practical matter, the state house Republicans understand that, if a large fraction of states decline to accept the federal money and expand Medicaid, a greater chance exists that, say in the next Congress, Republicans can repeal this law. Once most of the states sign on, the opportunity to repeal the law essentially ends.

  45. Good point. But irrationality extends to trying to repeal the Affordable Care Act. Health care in the USA has been a mess. At least the ACA is addressing some of the shortcomings.

  46. I don't believe they would ever repeal the law. After all they only work to insure their reelection so why alienate the millions of voters that now have health insurance?

  47. True, but that's not their job. Their job is to get the best deal they can for their citizens. They should ALL be impeached. Talk about dereliction of duty. If nothing else, accept it for two years--gratis the government--and then cancel it. Talk about 'What's the matter with Kansas' syndrome. My answer in large part is the media with exhibit number one Fox News. Blogs like Red State blah blah blah don't help, either.

  48. In Pennsylvania, the Governor is fearful that the Feds will renege on the Medicaid support as they reneged on the School support under Bush. The Feds want the states to start the programs with Federal money and then leave the states holding the bag. However, the stimulus that would occur in PA by taking the Medicaid money is too good to walk away from. In the end, Corbett will be voted out and the new Democrat Governor will accept the money.

  49. Thief Executive Scott will be replaced in November and Pam Bondi is going with him.

  50. The answer is also from business. Governors are like managers who run the companies for their maximum benefit in the short term and disregard the long term interests of the shareholders. Gerrymandering has created the equivalent of compliant boards of directors with legislatures controlled by a single party with safe seats. Take Wisconsin for example. It is simply not in Scott Walker's personal best interest (his desire to run for President in 2016) to expand Medicaid. The fact that the other states surrounding Wisconsin have expanded their medicaid has created an actual experiment in which Wisconsin seems to be posting worse economic results.

  51. To paraphrase the great H.L. Mencken, no one ever went broke underestimating the ideological stubbornness and willful ignorance of the modern Republican Party.

    My money is on the flat earthers. They have far too much certainty to let mere facts get in the way.

  52. Under straight economic theory, the poor should move to states that took the deal. Rational theory suggests you get more of what you reward.

  53. Yes.

    There are preliminary studies showing that "the homeless" are being directed to state capitals (e.g., with bus tickets) -- because those cities tend to have large numbers of workers (civil service) who can quickly process welfare claims.

  54. That may be true in your state, but in Texas the government has cut state employment such that it is actually easier to obtain service in the smallest nearby city that has the appropriate office. It is hard to cut 25% of the staff in a small office that only has 2 employees. Hence the ratio of employees to constituents in higher than the office that has lost 25 of their 100 employees.

  55. The answer to this question is quite simple:

    "Not only do these Republican states distrust Democrats for initiating the ACA, they distrust the GOP more for possibly reneging on the 90% repayment."

  56. Idealogues (heck, most of us) pick an choose what they worry about - for these conservative governors its the strings and future obligations that **they imagine** will come with acceptance of Medicade expansion - the welfare of their people be damned while they (mistakenly) believe they are protecting the wallets of their benefactors.

  57. Perhaps Rick Perry is thinking like an Economist. Specifically an economist who maintains that programs that target poor people disturb the Natural Order of Things by giving people stuff they wouldn't be able to afford otherwise, which destroys incentives to work for as little money as employers are willing to pay them. Thus making markets less efficient, and costing jobs.

    Doctors are in a tough position, because unlike their wealthy brethren that make good livings offering specialized services to wealthy people, they cannot afford to cater exclusively to those who can afford their high end services. At least not in their current numbers.

    Alas, Rick Perry must weigh the economic benefits derived by medical professionals against the evils of helping the poor. Caught between a rock and a hard place. If only the federal funds were going towards some great space project or weapons system, it would be a different story.

  58. The economist is puzzled that people aren't acting rationally. It reminds me of my first day of Econ. 101 in college, about 30 years ago. Economic theory, it was said, was built on the premise that people act rationally. I was immediately skeptical of the field. Since then, of course, behavioral economics has become a hot branch. So, nobody should be surprised that, while there is a case to be made for the wisdom of crowds, irrationality can rule the day. Especially when to sign on to a program means, in your simple mind, you are in effect ratifying the election of the type of person that cannot be a legitimate president. Talk about irrational.

  59. Then there is pragmatic economics - which can be summarized as there is no free lunch.
    Tell me - where is the federal portion coming from? Aren't they running a deficit right now?
    How about the state portion - aren't many states running deficits.
    Responsible spending and cost control is never "a deal too good to turn down"
    If it sounds like an infomercial it probably makes as much financial sense as an informercial

  60. A healthier population is a net economic gain in the long term, so borrowing to invest in it is a good investment. If you want to prove it wrong, go do the double blind test and then come back with statistics. Right now, massive federal borrowing to rebuild infrastructure (and create jobs) looks like another good investment. Of course, you can always opt to have your great-grand-children be unable to earn a living because transportation by high speed rail, and across rivers over bridges is not possible.

  61. In anticipation of States accepting the medicaid expansion, historical subsidies to non-profit hospitals (for indigent care) are being greatly reduced. The hospitals lose out in two fronts......removing previous funding and not gaining the new funding, while the patient load will remain the same.

  62. There's another factor behind the conservative governors' decision to refuse to expand Medicaid: the federal deficit and an unwillingness to contribute to its expansion by accepting borrowed federal money. Only a hypocrite would decry the ever-expanding federal budget on the one hand and then turn around and add still more to the burden we are bequeathing to our children and grandchildren.

  63. Let's see; would that be the currently shrinking deficit to which you refer?

  64. Yet you state no objection to federal tax breaks for corporations and for the wealthy, which also contribute to the deficit.

  65. I have seen that line in many movies: "Your money or your life" Which would it be more difficulty to deal with? Being in debt or being dead?

  66. I would argue that the not-yet-convicted felon Rick Scott wasn't actually in favor of the expansion. It was a thinly-veiled charade on his, and the state's Republicon (not a typo...) party. Scott knew full well the Republicons in the state legislature would reject it. Can't be giving medical coverage to all those 'lazy folk', you know....

  67. Dr. Reinhart sounds a lot like my wife after a shopping trip...."Look, Medicaid is ON SALE!! Run right out and buy some." Problem is, the popular narrative that it is somehow free is completely wrong. A couple of reasons why: 1. The Expansion does not cover the state's admin expense to sign up all the new people. Our non-expansion state conservatively advised they would have to hire 200-300 people to manage the workoad. 2. The Expansion does not allow for increases in reimbursements to your EXISTING Medicaid providers because you need to raise reimbursment rates to entice enough providers in to actually see the new population. Let's face it, most Medicaid systems are already at or over capacity. 3. There is still the 2.5%-10% of the reimbursement that must be raised at the state level to pay your share on a 10 year-model. 4. Every drop of money sent from Washington DC to the State's for this expansion is new spending and therefore borrowed money. The tax dollars we are supposedly contributing for other states is, at best, paying something towards the interest on that new debt. This is not a one-size-fits-all argument, the financial position of every state is unique. I personally think our state SHOULD expand, AFTER they have a vote of the people to decide how they want to raise our share of the required funds (taxes, cuts, whatever). This should not be a diktat from above. it should also not be a "cross your fingers and hope for the best" decision. WR

  68. None of your statements applies to Wyoming's case. We are nothing like your wife's bargain hunting. (I am feeling sorry for your wife.) Provider participation in Medicaid is nearly universal here, and reimbursement rates will not have to change. In fact, there is no rational reason for our legislative foot-dragging, unless you have a particular grudge against single adults without children.l

  69. I'd add one more thing to margherman's last sentence--or if you really hate anyone who works hard and isn't rich.

    As for Badlyread729, your state is truly exhibit A for the American descent to third world status. Terrrible education system made worse by your government, terrible health care stats, and heads buried deep in sand and rising gulf waters as you deny climate change.

  70. 1) The expansion does cover most administrative expenses and would cover more of them, except that Republicans in congress blocked the funding. 2) The law containes an increase in Medicaid reimbursement for primary care providers, EXISTING and new, that increases the rates to match Medicare. That provision, however, is temporary and expires at the end of the year. 3) True, but the increased economic activity as a result of the spending will provide most, if not all, of the revenue since Louisiana has income and sales taxes. 4) Unlike the Bush Medicare Part D drug coverage, all paid for by borrowing, every penny of the money expended in the ACA is funded by new taxes and fees or by cuts in existing spending. In fact, because Medicaid has not been expanded in many states and the subsidies for exchange purchased insurance are lower than expected, the ACA will reduce the deficit by far more than the $109 billion ten year estimate provided by the CBO in 2012. Those new taxes and spending cuts apply equally in all states.

  71. Come April, most shareholders vote to stay the course.

  72. The citizens who stand to benefit the most from expanded Medicaid coverage have the least influence on their obstructionist, elected representatives, mostly Republicans. Throw gerrymandering, selective voter suppression and the breathtaking influence of Super Pacs and there you have the grim picture. I hope Mr. Reinhardt is correct in his expectation that the medical community will turn this around.

  73. Gov. Rick Scott looks like a space alien.

  74. Here is the bottom line - when people do not have insurance everyone pays for it and they pay in the most expensive way. It benefits the population as a whole for all its members to be healthier - they are more productive, in the long run they cost the system less. Those who do not see the benefit of providing insurance to the working poor (because that is who is covered by the Medicaid expansion) are penny wise and pound foolish.

  75. This is your opinion. Do you consider a person who is poor, has no job, being more productive? I think not having insurance is a great incentive to remain healthy and to avoid risky things.

  76. There is no puzzle: Obama hatred has long trumped common sense and decency.

    The Medicaid rejection has deprived millions of essential health care.

    Good work, GOP. Feel proud?

  77. Nobody hates the president, we disagree with his policies and somewhat his tendency to ignore the constitution. Hate is a very severe emotion that I reserve for say child abusers.

  78. If this were an argument that the "Shareholders" actually understood the picture might be different. But the resistance is more a matter of an "Article of Faith" than a reasoned response to a real problem.

    Medicare, welfare, and the long list of social programs that get slammed by the Ayn Rand inspired "conservatives." The media spews out innuendo and half truth about these programs all circling around the truth that those who seem to "hate the government" are usually the same people who get the biggest benefits from the government while handing us the bill. The emotional argument is that by providing assistance to the poorest Americans, somebody is getting something that you aren't and it is coming out of your pocket when you pay your income taxes. There is no mention of the fact that more is granted to the wealthy and corporations that what is given to the poor.

    Nearly half the population of the USA makes less than the standard deduction for income taxes, middle income Americans have not seen a quantifiable increase in wages or salaries since the Reagan Administration and yet the cost of medical care and other essentials (which are conveniently not part of the inflation calculation) and the remaining Americans have seen annual growth in income and overall wealth over the same period of time.

    Wake up America - the Emperor (and his argument) is naked and you just don't want to believe it.

  79. How about allowing each state to decide what support they can afford. So progressive states would have extensive social nets that they would tax their citizens to provide. Others would have much less support as their citizens are willing to pay for.

  80. Well, stupid is as stupid does. Hopefully citizens in Red States will finally become aware that they are leaving money on the table and will vote their self interest. After all, Republicans are famous for espousing one set of principles for other people but then following their own rules when it comes to them or their immediate families, e.g., abortion, military service, paying their fair share of taxes, etc.

  81. Many of us in these states are not so selfish that we look at is as "leaving money on the table" but rather not increasing spending and taking risks of future tax increases.

  82. Funny how the death panel meme caught hold when Obamacare was proposed but when the real death plan to deny insurance to the poor and working and lower middle classes was implemented the Republicans cheered. And every single day, I see ads lying about Obamacare on my local TV news. The latest is supposed to be a local woman whose family started a small business. Supposedly they couldn't afford insurance anymore. The problem is that it's not true. There truly is no shame among those whose goal it is to deny medical care to all but the rich.

  83. You left religion out of the mixture. Ask what would the owner of Hobby Lobby do? According to the Protestant/Calvinist bent in this country, people that are poor are poor because of their own failings and their plight is the direct result of the god of Abraham's disapproval of them. (Same holds true to for those that amass untold wealth except that god is "smiling" on them.")
    Without recognition of the role, and the extent of that role both visible and invisible, of religion in how we treat our neighbors, our community, our selves, and our home planet we are dooming our children and their children to a painful extinction regardless of any wealth accumulated. We have no dominion over anything; we are part of the web of life. One can neither eat nor drink money.

  84. Anybody who believes this does not know many religious people. Now some poor people have made very poor choices which contributes to them being poor, others are subject to various outside sources.

  85. "Some governors and other Republicans have expressed fear that, in the end, the federal government will just renege on the deal now being offered, leaving the states to pick up the entire tab of the Medicaid expansion."

    That fear might be justified by the possibility that Republicans could regain control of congress and the presidency. If they do, the stated intention of Republicans if to repeal Obamacare, which would leave the states holding the bag for expanded Medicaid, and to adopt some form of the Ryan budget which includes the conversion of the rest of Medicaid to a block grant fixed at current levels so that eventually inflation will reduce the federal portion of funding to close to zero. That is what was done in the Clinton-Gingrich "end welfare as we know it" law. In 2014, in real dollars, states receive about 65.8% of the Federal funding they received in 1996 to assist poor families.

  86. You may have missed this: "But according to a federal document addressing frequently asked questions about the Affordable Care Act, states are free to drop out of the Medicaid expansion if they choose to."

    If the federal government reneges on THAT, states would have a good reason to sue and possibly win.

  87. My understanding is after you take the expansion you are stuck, so perhaps I am incorrect or perhaps you are.

  88. It's so good to see you back. Thanks for the column today.

  89. Just tried to get a friend's brother on medicaid who suffered from the ravages of systemic MRSA and strokes over the last month. As a florida licensed physicianI I could not find one to evaluate and manage his case. The system is broken no matter what politically correct steps appear to be beneficial. See how it works for the individual who for one reason or another has to use the "new"medicaid system.

  90. Comparing Medicaid expansion to a business is foolish. It is more like we can accept a deal that might cost us a lot of money in the future, or spend nothing more now without the risk. Now of course some individuals would benefit from the expansion but that is not like stockholders getting profit.

  91. Isn't medicaid going bankrupt in less than 20 years? Why would you want people being dependent on a system that is as of yet destined to be insolvent? I understand you may want to help people, but we can't help them if we don't fix the main problems of medicaid. I also think it is foolish to expand something that isn't currently working (yes people receive care, but for how long?) Perhaps we should fix the problems first and then expand the better system.

  92. Medicaid is a pay as you go system, so there is no bankruptcy (I believe you are thinking about Medicare part A). Please, can you be specific on how Medicaid is not working? I think it works pretty well for the folks that have it.