Rick Scott, Rick Perry: The State-Level Gauntlet-Throwing on the Affordable Care Act Begins

Well, here it comes: On Monday, Texas Governor Rick Perry, famous for his imploding Presidential campaign, said that Texas will not accept the Federal funding that would expand the Medicaid program there to insure all residents up to 133% of the Federal poverty level.  This announcement, by way of an open letter to Health and Human Services Secretary Kathleen Sebelius, has garnered a lot of attention over the past 3 days, but it is merely the most-emphatic case in a (still-small) wave of Republican-led States that have announced they will not follow the Federal Government’s lead in preparing for the reforms of President Obama’s Patient Protection and Affordable Care Act–including 1 provision that will cost little, doesn’t impose new regulations on health insurers or care providers, and which offers a lot of convenience for residents.

Texas has about 6.2 million uninsured people–about a quarter of  its population, the highest rate of uninsured in the United States–of which about 1.8 million people would have been insured through the Medicaid expansion and roughly 1 million more people currently qualify for Medicaid, mostly without realizing it.

Governor Perry, in an open letter to Health and Human Services Secretary Kathleen Sebelius, said that he opposes “both the expansion of Medicaid as provided in the Patient Protection and Affordable Care Act
and the creation of a so-called ‘state’ insurance exchange, because both represent brazen intrusions into the sovereignty of our state.” Sure, one could say Governor Perry is brazen in his callousness towards every 4th Texan who has to go without health insurance, but in his defense he only made this decision as an unprincipled and unimaginative self-promoter. Photo by Win McNamee (Getty Images).

The Affordable Care Act directs the Federal Government to provide 100% of the cost of the expansion of Medicaid for all States in 2014, the law’s 1st year of full implementation.  Federal matching funds would fall to 90% of all Medicaid expenses after 2016, as the Act passes into its 4th budget year.  15.8 million Americans were initially expected to receive health care through the expansion of Medicaid, about 1.8 million of them in Texas.  An NPR report 2 days ago found that another 1 million Texans currently qualify for Medicaid but apparently don’t know it, and that officials from the Republic of Texas are concerned that many of those people may also sign up with the program if it expands, thus straining Texas’ Medicaid program even with generous new Federal funding.

A post-Perry decision edition of a map charting State governments’ positions on the Federally-led expansion of Medicaid. These assessments of State support or denial are made very conservatively; in grey are many States–mostly with Republican Governors or Republican unitary control–that have issued skeptical or cautionary comments about expanding Medicaid but have adopted a wait-and-see approach to the Medicaid expansion, whether primarily for budgetary or political reasons. Click here to reach an informative interactive version of the map, which unfortunately gets a freakishly large number of the partisan affiliations of State governments wrong.

Sarah Kliff, writing on Wonkblog, presented a helpful map on States’ response to their new-found power to reject the Medicaid expansion without losing existing Medicaid funds from the Federal Government.  (Unfortunately, this map was already dated due to Governor Perry’s announced rejection of the Medicaid expansion, on which Kliff was reporting.)  According to the updated map, Florida, South Carolina, Louisiana and Mississippi already preceded Texas in denying the expansion of Medicaid.  The same map lists New Jersey (by means of Republican Governor Chris Christie, not the very-Democratic State Legislature), Missouri, Iowa, Nebraska, and Nevada (again, through a Republican Governor) as proposing to opt-out of the Medicaid expansion.  With the exception of Nevada, which has already created its health insurance exchange, the remaining 9 of these States are also probably not going to follow-through on creating State databases that allow consumers to compare and pick insurance plans online.  Consider this: At least 9 States, all but Missouri with Republican Governors, are planning to forego instituting health insurance exchanges that would simply provide information to their citizens that would make choosing a health insurance plan more-competitive and convenient, leaving the power to create and maintain such a website (which thus may not be tailored to local consumer preferences) to the Federal Government, just to be on-record not doing anything to further “Obamacare”.

The Henry J. Kaiser Family Foundation’s map of State action to create the health insurance exchanges mandated by the Patient Protection and Affordable Care Act as of July 9, 2012. States are required to create the exchanges, which would provide residents easy access to information about the costs and benefits of different health insurance plans, by January 1, 2013 or else the Federal Government will create the exchanges for those States. All States’ health insurance exchanges are set to go online no later than January 1, 2014. The Commonwealth of Massachusetts and the State of Utah, respectively the most-Democratic and the most-Republican State in the country in Presidential elections, each instituted their own health insurance exchanges before the Affordable Care Act became law. Though Rick Snyder in Michigan has been one bright spot, many of the Republican Governors and State Legislatures elected since 2009 have implied or even stated that they won’t create their own health insurance exchanges even though they are mainly a matter of convenience for insurance-buyers.

Of course, Republican Governors have this leverage because of last month’s Supreme Court ruling on the Affordable Care Act.  In a 7-2 decision, the Court found that the Federal Government could not threaten States that declined to participate in the expansion of Medicaid with the loss of funds for the current Medicaid program.  Intrinsically, this was the most-radical part of the ruling by far, as it subjected 1 of the farthest-reaching reforms of the Patient Protection and Affordable Care Act to the discretion of the States.  (Though the Federal Government disburses money to State and local governments with conditions all the time, the expansion of Medicaid represented a far-reaching change to Medicaid, and while the 90% Federal funding for the expansion from 2020 onward was generous, it would leave States like Texas with up to several billion dollars in new liabilities.)

Don’t take my deference to the Court’s finding that the steep Medicaid penalty on the States was unconstitutional for sympathy towards those Republican Governors who have said they will opt-out of the expansion of Medicaid.  Just because the Federal Government doesn’t have the right to compel State action doesn’t mean it isn’t immoral for States not to act.  At 10 cents on the dollar, States can have the health care needs of all of their poor and their borderline poor covered through Medicaid (as long as they are citizens).  Some of the Republican Governors, such as Michigan’s Rick Snyder (who has actively promoted the creation of Michigan’s health insurance exchange in its Republican State Legislature), do seem serious about studying the impact of the Medicaid expansion on their State budgets and the number of the uninsured before making a decision.

While he is mistrusted by many on the left for the legislation he signed authorizing radical emergency financial management for financially-stressed cities and school districts, Michigan Governor Rick Snyder seems to be serious about studying the impact of a Federally-led expansion of the State’s Medicaid program before deciding whether to accept the money. It’s a nice contrast to the patronizing partisan gestures that have become hallmarks of the governing styles of Rick Perry, Rick Scott, Bobby Jindal, and Paul LePage.

The telling counterpart to this cheap show of Conservative virtue is several States’ refusal to create health insurance exchanges.  True, any State that misses the January 1, 2013 deadline to institute their own will see the Federal Government institute an exchange for them by January 1, 2014.  But while the consequences of refusing to create an exchange on their own motion would be minor, the benefits of creating their own could still be substantial, if State elected officials were willing to be associated with President Obama and Congressional Democrats.  If this were a money issue, a State could still ask the Federal Government for guidance in creating its health insurance exchange, which Conservative-Democratic Arkansas did.  The State of Utah–Republicans’ partisan counterpoint of the District of Columbia in Presidential elections–actually had a health insurance exchange that passed Federal muster before the Affordable Care Act became law.  The fact that so many Republican-run States haven’t taken any action to institute their health insurance exchanges with a Federal deadline approaching at the end of this year is telling: They have been asked to create a consumer-friendly interface for accessing information on different health insurance plans, and they won’t do it because it indicates cooperation with President Obama.  When Governors will not take minimally-costly action out of convenience for their middle classes to create health insurance exchanges, this is the light in which their inaction for their less-fortunate State residents should be viewed.

Some have calmly argued–though without approving of this tactic–that these Republican Governors are  playing hard-to-get in order to bargain with the Federal Government for greater flexibility on how to expand Medicaid.  That could be an illuminating, rationalist explanation; on the other hand, the Republic of Texas has an easy lead in the number of executions by State (even as its criminal justice system in some counties has been shown to be flawed in capital cases), and the State of Florida just intentionally made it very difficult to lawfully help anyone register to vote.  These States really don’t seem to have governments that are working-out all the angles to do what’s best for their residents; rather, they seem to be led by partisan hacks trying to build-up their reputations for–No, now I’m speculating…

The Liberal Ironist is serious about Liberalism–in Richard Rorty’s understanding, the sentiment that politics should aim to lessen the cruelty of “the World”–but I am also “serious about irony”–about the suspicion that all modes of understanding accessible to us are ultimately human creations rather than transcendent truths.  I do not embrace any binary that “Democrats are good” and “Republicans are evil,” not even in its better-disguised variations.  That said maybe a dozen States, mainly at the behest of their Republican Governors, are in the process of denying anywhere from tens of thousands to millions of their poorest residents access to health care that is mostly paid-for by the Federal Government (and through which their residents will pay most of the taxes regardless of their decision), so that they can set-up another procedural hurdle to a health care law that today plays a more-coherent role in Republican mythology than any policy the party will propose this Presidential Election year.  How convenient that we have a map marking-out the States where Governors have decided to leave their people uninsured, the better to play more-Conservative-than-thou.  The Liberal Ironist hopes you will check the originals now and then for updates…


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