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The Medicaid Silver Linings Playbook

Posted by John McDonough  February 5, 2013 07:11 PM

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On Monday, Ohio's John Kasich became the fifth Republican Governor to embrace the expansion of Medicaid, as permitted by the Affordable Care Act (ACA, Obamacare). "I think that this makes great sense for the state of Ohio," he said.

Of course, until last June 28, expanding Medicaid was not an option for states, and was included in ACA as a mandate. U.S. Supreme Court Justice John Roberts convinced a majority of his colleagues to make Medicaid expansion optional, the major change in the ACA from the Court's ruling, one I like to call the "Roberts Rule."

Last week, I was in Washington DC at the annual conference of Families USA, the national consumer health advocacy organization. In talking with folks from states now grappling with how to convince Republican governors and state legislators to expand Medicaid, I have developed a counterintuitive hypothesis for your consideration:

The June 2012 Supreme Court decision making the Medicaid expansion a state option will turn out, politically, to be enormously positive, perhaps even a game changer, for the future of the Medicaid expansion in particular and the ACA in general.

Now don't get me wrong! If I had my druthers, the expansion would be mandatory, and I believe that the damage to be done by the Roberts Rule will be serious.

First, the decision enshrines health care rationing as explicit federal policy. Because of it, the only U.S. citizens without guaranteed access to health insurance will be poor men and women in states that do not expand. Republicans like to accuse Democrats of rationing as a favored epithet. The Roberts Rule is rationing for real.

Second, make no mistake, poor and mostly minority Americans will die because of this rule. Dr. Ben Sommers and other colleagues at the Harvard School of Public Health, have done the research -- uninsured people are more likely to die than Americans covered by Medicaid.

So don't get me wrong. And yet:

The Roberts Rule fundamentally changes the basic political dynamic of the ACA's Medicaid expansions (Title II of the law). As of today, five Republican governors have announced their intention to participate on the starting date of the expansion, 1/1/2014, notably arch-Obama critic and Arizona Governor Jan Brewer. Also on board are New Mexico's Susana Martinez, Nevada's Brian Sandoval and North Dakota's Jack Dalrymple

So instead of them castigating Obamacare, we now see five Republican governors (more to come...) explaining to their states why embracing this huge coverage expansion makes sense. In her January 14th State of the State address, Governor Brewer emphasized the "enormous economic benefits" from the expansion. The massive wall of Republican resistance to the ACA is crumbling, starting with Republican governors. And it's all due to the Roberts rule. [To be clear, it's hardly unanimous -- at least 12 Republican Governors have rejected the expansion, with Pennsylvania's Tom Corbett today becoming the first blue-state Republican to nix the expansion.]

But let's not underestimate the importance. If immigration reform happens this year, it will be far less controversial than the ACA because Republican senators such as Florida's Mark Rubio are on board. Division over the ACA has been so intense because no Republican office holders embraced it. That is now changing in front of our eyes -- and it's important for Medicaid and for the ACA.

Further, the imperative to mobilize strong, new political coalitions to lobby governors and legislatures to embrace the expansion is creating powerful alliances between state consumer advocates and key health system stakeholders such as hospitals, physicians, insurance companies, and even business groups. In conservative Missouri, the state's Chamber of Commerce has endorsed the Medicaid expansion.

In these fights, consumer advocates are the smart ones, explaining how state taxpayers will finance Medicaid expansion in other states whether or not they embrace it themselves. To reject 100% federal financing in 2014-2016, and no less than 90% after that, is, well, to borrow the word of Louisiana Governor Bobby Jindal, "stupid."

So much of the opposition to the ACA is based on the public's flawed understanding of "Obamacare" as a whole. Though the American public is sharply divided in their judgments of the ACA as a whole, they are also strongly in favor of most of the law's major elements. The Medicaid conversation takes the public's attention away from the ACA and whole, and focuses it on one of the most important and favored part of the law.

Finally, one more: because of the Roberts Rule, White House and Congressional Democrats were unwilling to put Medicaid cuts on the table in the budget sequestration process. The ACA's Medicaid expansion was designed as a carrot and a stick -- when the Supreme Court removed the stick, the Obama Administration realized they could not risk chopping down the carrot.

Just as the nation's political ground has shifted on immigration, guns, and taxes since the November 6th, the ground now is shifting on the ACA. We may finally be reaching the point where Congress can get about the normal business of overseeing the law's implementation and focusing on areas where it needs improvement and fixing.

And, surprise, most of it is thanks to the Roberts Rule.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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