In 2014 the Patient Protection and Affordable Care Act, which supporters and detractors alike refer to as Obamacare, will offer individual states the opportunity to expand Medicaid coverage. Those that accept that invitation, an action that requires legislative approval, are succumbing to a siren’s song and are bound for the same collision with rocky shores as those sailors in Greek mythology.
Medicaid was established in 1965 and is jointly paid by state and federal funds. All 50 states have agreed to this voluntary arrangement and participate in the program, a means-tested entitlement intended to help low-income individuals, families and certain others afford health care.
The 2014 expansion dramatically increases the number of people eligible to enroll. The federal government will pay all of the increased cost for those states that choose to expand their Medicaid programs and use the federal government’s promise of money to do it.
At first, most of the nation’s 30 Republican governors said no. That number is changing, with at least seven now agreeing to use Washington’s help to expand their programs. Their reasons could be summed up by Florida’s Republican governor Rick Scott who says, as reported on the PBS Newshour, “While the federal government is committed to paying 100 percent of the cost, I cannot, in good conscience, deny Floridians that needed access to health care. We will support a three-year expansion of our Medicaid program under the new health care law, as long as the federal government meets their commitment to pay 100 percent of the cost during this time.”
Getting 100 percent of the cost poured into your treasury is hard to resist at any time and with state resources being pressed, it is a particularly difficult decision these days.
The more subtle motive might be a wish to be re-elected. That desire, not restricted to members of any political party, often trumps sound policy.
Several years ago I was watching a movie depicting the tough times facing people in rural areas during the early 1900s. Part of the story involved a new federal program being offered as subsidies to farmers and ranchers to help insure against losses when prices were low. One obstinate fellow in bibbed coveralls and work boots argued that to take that money would create a dependence that would forever make farmers reliant on federal subsidies.
It was an after-the-fact movie. The results predicted by that character had already come to pass. It was illustrative, however.
Medicaid expansion is the same thing. While Scott says his state will stay in the program for the three years that Washington will pay 100 of the cost, it is wishful thinking that once Florida or any other state buys into the concept it will be able to wean itself of the support when the subsidy decreases. Further, as is the case with Medicaid, the federal government has rules that must be followed if the money from Washington is to continue to flow. The term “voluntary” loses some of its meaning with that condition. He who holds the gold makes the rules.
In 1973 Congress passed a law for a national maximum speed limit of 55 mph as a fuel-conservation measure. Failure to comply would cost the states their federal highway money. While compliance was voluntary, states did not want to give up the dough. The restriction had little effect on fuel consumption.
That same hard-to-give-up financial dependence comes with this program.
It is also monetarily inefficient. The federal government collects the money and sifts it through federal level administrative sieves. What comes out and goes to the states is less than what went in. Those fewer dollars go through more administrative thinning at the state level before reaching the people who are supposed to be getting the help.
Government employees doing this administrative “skimming” at every level will be happy because they have jobs. The people receiving assistance, except perhaps that fellow in bibbed coveralls and work boots, will be happy, too. This larger set of beholding voters will make opting out of the program later nearly impossible.
Centralized decision making is on the rise. The opportunity of the citizens of various states to figure out what works is decreasing. Homogenizing the country continues. With reduced opportunities to try different ways of doing things, the synergy of ideas is blunted.
Hawkins is retired after 35 years as a construction industry association manager. He was a broadcast reporter and news anchor in Denver, Colo. As a Navy officer, he saw action in Vietnam in the River Assault Squadrons and is the recipient of a Silver Star and Purple Heart.
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