Republicans in Congress and statehouses across the country harbor an antipathy to Medicaid that is impossible to explain, except as hostility to the poor families that are its chief beneficiaries.
Sam Brownback, the GOP governor of Kansas, translated ideology into action on Thursday when he vetoed a bill that would have made Kansas the 32nd state to expand Medicaid under the Affordable Care Act. The measure would have brought health coverage to as many as 180,000 of his state's residents, with the federal government picking up 95% of the tab this year. Yet in his veto message Brownback called the expansion an "irresponsible" budget-buster.
That's not the only flaw in Brownback's statement. He calls Medicaid a "welfare" program, which isn't true, and alludes to "restarted negotiations" in Washington, D.C., to repeal the ACA, which already have broken down. He gripes that the expansion bill passed by the Kansas legislature doesn't cut off funding for Planned Parenthood, which of course is a Republican blind spot that no medical treatment can probably cure. He also took a coded swipe increasingly heard from the GOP by identifying the expansion beneficiaries as the "able-bodied." More on that in a moment.
First, let's examine some of the other common right-wing slams of Medicaid. One often heard from House Speaker Paul D. Ryan, R-Wisc., and Health and Human Services Secretary Tom Price is that Medicaid patients can't find doctors to treat them. "One out of every three physicians in this nation aren't seeing Medicaid patients," Price said recently; Ryan's version, uttered during a press conference earlier this month but repeated endlessly, is that "more and more doctors just don't take Medicaid….That is a huge, growing problem with Medicaid."
Of course, Price's calculation means that more than two-thirds of doctors do accept Medicaid patients. Nor is there any evidence that that figure is generally falling. Nationally, according to the Kaiser Family Foundation, Medicaid patients' access to care and their satisfaction with their coverage is very close to that of people with employer-paid insurance — and way ahead of people with no insurance.
The percentage of doctors accepting Medicaid patients does vary widely among states and metropolitan areas, but that mostly has to do with physician reimbursement rates, which vary state-by-state. There's an obvious remedy for that local effect and the national acceptance rate, well within the power of Ryan to rectify, with Price's help: raise the reimbursement rates, which are well below those paid by private insurers and Medicare.
Conservatives love to assert that Medicaid does little to improve the health and well-being of its enrollees. That's also contradicted by the facts. A study led by Benjamin Sommers of Harvard's school of public health compared health statistics in Kentucky and Arkansas, which expanded Medicaid, with Texas, which did not. It found that in the expansion states, enrollees were far less likely to skip medications because of cost, spent much less out-of-pocket on care, and had fewer visits to the emergency room. Diabetes screening was improved, as was regular care for chronic conditions. Medicaid enrollees reported improved healthcare quality and described their own health as better.
Nevertheless, expansion opponents continue to rely on these myths, as well as the argument that Medicaid expansion is somehow a handout to "able-bodied" Americans at the expense of enrollees in traditional Medicaid. Traditional Medicaid targets children and their parents, while the expansion brought in childless adults with household incomes up to 138% of the federal poverty line. Among the subtexts here is that the federal government pays less of the cost of the traditional program than it does of the expansion. The government's share of the latter will drift down to 90% in 2020 and remain there, unless Congress changes it.
The notion that able-bodied Americans are getting away with something is what animates the crusade to add work requirements to expansion Medicaid. The flaw here is that Medicaid is not a welfare program for the jobless, but a healthcare program. Its benefits never have been predicated on recipients' seeking or holding a job, in part because that's unnecessary: About 80% of all Medicaid recipients already are members of working households, and 60% are working themselves. Of the others, according to a 2016 survey by the Kaiser Family Foundation, all but 3% are ill or disabled, going to school, are family caregivers at home, retired, or unable to find a job. In other words, work requirements appear to be more an ideologically punitive step than a practical one.
Brownback isn't the only state-level Republican to continue opposing Medicaid expansion. The North Carolina legislature is still trying to thwart the efforts of the newly elected Democratic governor, Roy Cooper, to implement expansion. They've filed a lawsuit asserting that his effort to do so unilaterally would violate a 2013 law that requires legislative approval; Cooper's position is that the law infringes on his constitutional prerogatives as governor. Coverage for as many as 500,000 low-income residents hangs in the balance.
The Idaho Senate earlier this month rejected a Democratic plan that would have brought an estimated 78,000 residents under Medicaid's umbrella, and the idea appears to be dead for the year. Republican Gov. Butch Otter has said that expansion "would mean subordinating our Idaho priorities to the siren song of federal dollars." In Missouri, Gov. Eric Greitens has blown off a Democratic legislative effort to expand Medicaid. Republican legislators in Virginia remain united against Democratic Gov. Terry McAuliffe's drive to cover as many as 400,000 Virginians.
Elsewhere, the collapse of House Republicans' ACA repeal measure has prompted Republican-dominated statehouses to reconsider their long opposition to Medicaid expansion. That includes Georgia, where Gov. Nathan Deal said he would consider some form of expansion, possibly through a federal waiver that would allow the state to fashion its own version of expanded Medicaid. But that probably won't happen this year, and opposition remains strong in the legislature.
Brownback's veto was expected, because although the legislature's expansion measure won great support even among Republicans, it didn't reach the two-thirds majority needed to override a veto. Efforts are underway now to drum up enough additional votes to do so within the 30-day window allowed by Kansas law.
Supporters of expansion have reason to find Brownback's veto message especially irksome. That's because he contends that the expansion would place a burden on the state budget. "The cost of expanding Medicaid under ObamaCare is irresponsible and unsustainable," he wrote. The major burden on the Kansas budget comes from Brownback's own policies, which encompassed huge tax cuts that brought great benefits to the state's higher-income residents while leading to ruinous budget cuts for state services and schools. Brownback defended the tax cuts as the key to supercharged job growth, but that hasn't happened. Instead, economic growth in Kansas has fallen behind the country as a whole, its neighbor Missouri, and states that pursued a more rational budget policy such as California, which has left Kansas in the dust.
Given Brownback's insistence on the wisdom of his policy despite its obvious failure, no one had a right to expect he would take a smarter line on Medicaid expansion. Nor have the other Republican state leaders who are clinging to their dead-end notion that they should turn up their nose at billions of dollars in federal funds to bring healthcare to hundreds of thousands of their residents. If the failure of the House GOP's repeal measure doesn't show them that it's time to get on board with Medicaid, what will?