There are two (okay, technically three) recommended reads building off yesterday’s post on Ross Douthat and the implications for a successful Medicaid expansion in the Affordable Care Act.
To begin with, though, let me reiterate that there is a bit of a ‘slatepitch’ to be made that conservatives should be rooting for the online marketplaces in the ACA. This is because they have, at least in the past, reached something of a consensus on reforming both Medicaid and Medicare into voucher-like (re; premium support) programs wherein folks would shop for insurance coverage on regulated exchanges.
The line of thought doesn’t end there, though, as it’s historically understood by some that conservative reform efforts like Paul Ryan’s Patients Choice Act and later premium support proposals exist largely in reaction to liberal initiatives. So this contrarian argument doesn’t exist in a vacuum of self-motivated reasoning, but in imagining a possible future where the ACA exchanges don’t work very well but the Medicaid expansion does. In that alternative timeline of reform liberals would have a strong incentive, and proven example, for further streamlined government provision of health coverage. The question, then, is what policy would conservatives counter with that didn’t look like the failed effort to foster well-functioning private insurance markets?
There may not be a good answer, but tangential to efficacy of Medicaid is this first piece of recommended reading over from the New York Times on state-level efforts “to foil health care law.” The conservative political advocacy group Americans for Prosperity is spending millions of dollars and coordinated street-level organizing to prevent states from accepting the Medicaid expansion. Beyond simple ‘awareness’ campaigns, they’re also targeting local decision-makers:
One leading target is Emmett W. Hanger Jr., a Republican state senator from the deeply conservative Shenandoah Valley, who prides himself on “going against the grain.” As chairman of a commission weighing one of the thorniest issues in Virginia politics, whether to expand Medicaid under Mr. Obama’s Affordable Care Act, he is feeling heat from the Republican right.
His openness to expansion has aroused the ire of Americans for Prosperity, the conservative advocacy group backed by the billionaire industrialist brothers Charles and David Koch. Dressed in emerald green T-shirts bearing the slogan “Economic Freedom in Action!” its members are waging what the senator calls “an attempt to intimidate me” in Richmond and at home.
They have phoned his constituents, distributed leaflets and knocked on 2,000 doors in his rural district. When the Republican town committee met Monday night in Mr. Hanger’s home county, Augusta, Americans for Prosperity was there.
Included in that article is an argument from conservative activists that Medicaid actually causes worse health outcomes. Which is to say, they’re opposing the expansion because “folks that need the most help will get hurt the most.” This is an old contention well-disputed by myself and others, but because it’s recurring here’s Paul Krugman restating the obvious in your second recommended reading:
O.K., you know what to do: Google “spurious correlation health.” You are immediately led to the tale of certain Pacific Islanders who long believed that having lice made you healthy, because they observed that people with lice were, typically, healthier than those without. They were, of course, mixing up cause and effect: lice tend to infest the healthy, so they were a consequence, not a cause, of good health.
The application to Medicaid should be obvious. Sick people are likely to have low incomes; more generally, low-income Americans who qualify for Medicaid just tend in general to have poor health. So pointing to a correlation between Medicaid and poor health as evidence that Medicaid actually hurts its recipients is as foolish as claiming that lice make you healthy. It is, as I said, a lousy argument.
The humanistic appeal that Medicaid is worse for people than remaining uninsured may be more important than folks realize. At the ground level, when you’re trying to convince folks to oppose covering low-income individuals, you probably need something more convincing than something along the lines of “you should agree with my ideological first principle in the government provision of social services.” People detached from the bubble of day-to-day clashes over political philosophy need a practical reason to get involved — hence, preventing folks from getting hurt.
That this is a spurious assertion underlines the ethical dubiousness of focused efforts to leave low-income Americans unprotected from the uncertainty of being uninsured. Proposals like universal catastrophic coverage, or even The American Health Care Reform Act, seem to act mostly has bulwarks against such criticisms. Yet Groups like Americans for Prosperity, and many elected Republicans, aren’t concentrating on practical alternatives to getting folks access to the health care system. In this instance at least actions really do speak louder than words.
For serious conservative alternatives, look towards Arkansas and Michigan. Both of those Republican-controlled (in one form or another) states are moving ahead with expanding Medicaid, albeit through privatized compromises with the Obama administration. To quote Adrianna McIntyre making the same point, other red states have a real opportunity to push folks towards a more private health care solution:
But expanding Medicaid through the exchanges is achievable in the near term for the 26 states still opposed to expanding the public program (Iowaand Pennsylvaniaare exploring the option.). As Ross Douthat points out, conservatives find fault in the new marketplaces, but they’re “closer to the right-of-center vision for health care reform than the Obamacare Medicaid expansion”.
So, again, it is plausible that conservatives should be wishing for a mostly-successful insurance marketplace experience to avoid the possibility of a stronger case for single-payer or a public option. However, instead of hoping and laboring towards Medicaid failure maybe they should be actively working to successfully privatize low-income coverage as well. To do that though requires admitting that any coverage is better than none, which in light of activist and broader party efforts seems like a huge first step.