Republican State Lawmakers’ Refusal to Expand Medicaid Will Result in Thousands of Deaths

While this site has been critical of the (Un)Affordable Care Act as a further subsidy to an already bloated medical-industrial complex, we do need to give the devil his due. One of the sections of the law that appears to have been genuinely beneficial is Medicaid expansion. However, as most readers well know, the results are inequitable, with poor people in Republican states that refused to take up this provision being left out in the cold. As this Real News Network segment with Dr. Steffie Woolhandler, professor at the CUNY School of Public Health at Hunter College and visiting professor of medicine at Harvard Medical School, shows, the failure of Republican states to participate in Medicaid expansion has significant human costs.

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  1. TimR

    Wait a minute, she seems to be pulling a fast one here, dancing around the numbers. First she claims that after 3 years, the Feds pick up 90% of Medicaid expansion; then she seems to concede that “in the long term” it will drop off more, but that doesn’t matter because, paraphrasing, “usually states are short-sighted and only plan budgets for the next 3 to 5 years, so why should they care what happens beyond that” !!

    If her argument is strong she should be more straightforward about the numbers, not gloss over them like the long term is trivial. I’m still unclear if the 90% is in perpetuity or if that drops off at some point and the Rep lawmakers have a legit concern. Incredible that she tries to suggest SOP is budgeting for 3-5 years, so nobody should worry themselves over states’ long-term budgets.

  2. TimR

    On Medicaid expansion and Ocare, I have some questions that are relevant to my own situation, apologize if there’s not general relevance to NC..

    1) If you are probably eligible for Medicaid, but don’t attempt to sign up for it (and thus lack insurance) will you face a probable tax penalty? i.e., do you need to have proof you tried to sign up and were rejected to avoid a tax penalty?
    2) Do you have to sign up for Medicaid every year and keep getting rejected (due to living in a cruel cruel red state) to keep avoiding the tax penalty?
    3) Or is it even worse than that — is there some sort of requirement maybe to apply every month if your income is variable? I heard tell of some measure like that… Hope it’s not true…

    1. Jim Haygood

      If you’re under 65 and have no health coverage, the site is supposed to either enroll you in Medicaid (if eligible) or else in a health plan subsidized according to income.

      The designers of the system didn’t foresee anyone ‘getting rejected’ — there’s something for everybody. But it didn’t occur to them that even with a subsidy, some folks can’t afford a new monthly bill, plus deductibles and co-pays on top of the premium.

      And then there’s the hardcore, antisocial refuseniks, whose stance is ‘can pay, won’t pay.’ ;-)

      1. TimR

        I was trying to avoid the website because A) I don’t like how it collects all your info first, then slots you into something, without giving you a way to get some perspective on the mechanisms involved, B) horror stories about all the different agencies with access to lots of consolidated personal info, and hackers saying how weak the site is, and probably C) yes I’m a bit of a curmudgeon.

        But actually, even if one could afford Obamacare, or health insurance generally, I think there are other reasons besides being “antisocial” to not want to be involved with “the system.” For one thing, the mandatory requirement to give money to a private company is different from paying taxes to the government (where there is at least lip-service to the idea of public control of those funds, and public benefit.) Why should a private company get to impose a tax on citizens, not just through the usual means of monopoly control of markets, but now even with government mandate on its side? Further, I for one find healthcare itself to be cartelized, close-minded, and exclusionary of alternative healthcare traditions and practices. This extends to the scientific establishment, academia, and medical journals, creating a model in many ways antagonistic to the goal(?) of health and well-being.

    2. TarheelDem

      I’m not sure that anyone has properly considered the variable income problem. Consider that most retail workers now work on an as-called part-time basis in which they “compete for hours”. Given the level of income to qualify for Medicaid, it would be very easy for these workers to cross back and forth across the qualification line during the year.

      Politically, having people get a tax penalty because they were caught in a the contradictions of the law and rules and state opt-outs is likely to be a front page story. It is or should be one of the top items on the list of legislative fixes by Congress.

      Another fix that should be at the top of the list is eliminating co-pays, deductibles, and balance billing in health care billings. Patients should not have to have out-of-pocket expenses given the size of the premiums. Nor should patients take up the slack when there is a dispute between the insurer and the provider. In my opinion, having to deal with this issue can only result in a single payer system, one with gargantuan premiums, or one with near-zero profit for insurers and providers.

      1. different clue

        Dare one suspect that the reason for such high deductibles and copays (other than to spare insurance companies from as much payout as otherwise on premiums) is to encourage people to forgo health care until the become terminally diseased? In order to get as many people as politically cover-uppable to die before they get old enough to go on Social Security?

    3. sleepy

      If you live in one of the red states that has not expanded medicaid, and you fall in the gap between “medicaid eligible” and “exchange eligible” you will not pay a penalty. There is a condition for the penalty to apply–your premium must be below a certain percentage of your income, or you’re exempt.

      I am assuming that exemption applies.

      I would also assume that you go through the procedure every year.

    4. washunate

      You can get what is called a hardship exemption from the individual shared responsibility payment. It’s pretty easy, since most anyone without health insurance is, by definition, facing some kind of hardship.

      If you’re under 30, you can also apply for an extra junky junk plan (catastrophic coverage).

  3. MarkJ

    In Indiana, a state dominated by a Republican administration, the Medicaid expansion portion of the ACA remains unimplemented. The cost for Indiana to implement the ACA for the first year? About $170 million dollars. Indiana’s budget surplus for last year (2013)? About $500 million dollars. Indiana’s budget “reserves” for 2013? $2 billion dollars.

    The Governor’s plan for the budget surplus? Tax cuts for the rich.

    “Its deja vu all over again”. (Yogi Berra)

    1. sleepy

      Arkansas and Iowa have gotten certain waivers for the medicaid expansion. Basically they are taking the money and using it to purchase private insurance policies for the medicaid eligible.

      I don’t know much about the quality of these plans–I would imagine they are overpriced and skimpy–but I’m surprised that more repub governors haven’t used this to shovel more public money to the private companies.

      Medicaid and Medicare privatization is the goal anyway.

  4. Banger

    One of the great puzzles I have seen in recent years as the Republican right has moved rapidly down the rails to a kind of nihilism is why opponents of the right who are basically composed of centrists and centrists who claim to be on the left don’t bring up the fact that what these guys are arguing for is exactly what Ebeneezer Scrooge argued for in his famous speech. These guys really do want people to die. It would seem to be so easy to cast them in that light. These are just people with a simplistic ideology these are people who want the poor and disabled to die or at least suffer a great deal. They ignore morality (Biblical morality requires us to take care of the poor and sick), ignore science, ignore even self-interest in the perverse joy of seeing people suffer.

    So why isn’t this argument front and center? It is accurate and no right-winger can deny it if we follow logically the implications of their policies–but the opposition centrists don’t make this claim but kind of skate over it. As for the left, it just waves its arms and mutters inarticulate incantations about “the rich.” This is an issue that transcends class-struggle, it is a deeply moral issue.

    1. Banger

      BTW, I just talked to someone a few weeks ago who was rejected for Medicaid in North Carolina–he is lost between the cracks. His situation might get resolved who knows. I believe he and others need more than a website but social workers to be proactive and reach out to people who are scared and suffering.

    2. Jagger

      You are absolutely right and I have no clue why the “opposition” doesn’t point out the obvious. The argument is simple, clear and obvious and yet we never hear it. Just another example of the insanity of modern day American leadership.

      1. NotTimothyGeithner

        The problem is the Democratic Party ignoring the allure of greed is largely composed of people who came of age during the 70s and 80s. With the rapid rise in inequality and tendency to think of ones self as average at the same has to a situation where Democratic candidates and donors see the accumulated wealth and are inured from harsher realities From their perspective, Reagan is great partially because Democratic followers are too soft and won’t challenge their bizarre world views in public.

        In many ways, they missed the fights of the 60s and have focused on their class problems such as gay marriage which affects all classes especially higher economic classes because lgtb types are more free to be themselves in wealthier neighborhoods.

        When you ask why they don’t do this, it’s important to remember they are doing a great from their perspective. Party recruitment after Watergate was important as the Dems sought to capitalize on the anti Washington wave with outsider candidates which led to Carter who was a bridge to Clintonistas.

        Medicaid isn’t a concern to them personally, they have no understanding of the insanity of allowing the GOP to be the arbiters of who gets the expansion. Can an advocate for state based policies make a convincing argument the fault is a random governor when he should have demanded a national solution especially when the critics of A A were so vocal for so long while being denounced as racists and dreamers? The current Democratic elite isn’t that smart partially because they have missed suffering or lacked shared experience, and if they were that smart, they would have avoided this mess.

      2. Code Name D

        My theory is because Centrist Democrats are not nearly as ideologically different from Republicans as they would have us believe. Democrats don’t make this kind of argument because the think its inappropriate.

        Both believe that it’s the “consumers fault” that healthcare costs have gotten so out of whack. If they would have just made better decisions, then we wouldn’t be in this mess.

        The Republican approach is to maximize the pain for these “poor decisions” thinking that consumers will eventually come to make correct decisions. Not unlike how sticking your hand in a fire teaches you not to stick your hand in the fire again. From their point of view, all of that government intervention prevents this lessen from being learned. Putting an oven mitt the kits hands is not how you teach them about fire. This only extends the pain. When they say they can’t afford Medicare expansion, this is what they mean. The fact that the government is paying for it… is NOT what they are talking about.

        Democrats are some what more empathetic. They argue that consumers have made poor choices because those poor and unfortunately poor people just don’t know any better. So Democrats want to educate us to make proper decisions and to give us the means of doing so. So they like to talk about exchanges and consumer outreach programs. They have become increasingly willing to embrace mandates to force consumers to make proper decisions. Apparently those poor… poor people are just slow learners.

        This is the false dichotomy between letting consumers fail in the free market vs helping consumers make better decisions. Both remain consistent within the free market orthodoxy however, and it’s the free market itself that needs to be challenged. Poor people don’t have insurance – because they can’t afford it. It’s not a mater of choice, so providing more choices, encouraging better choices, or fancy ad campaigns to make people aware of choices is an exercise in futility.

        On a side note: I observe Democratic apologist running for the Medicare expansion as proof that Obamacare works and is popular. Yay, the one program that Obamacare didn’t create – works just fine. I just saw the Young Turks bloviating about how suddenly popular Obamacare has become with Republican voters. I note that they didn’t cite any sources.

        1. tongorad

          “So Democrats want to educate us to make proper decisions and to give us the means of doing so. So they like to talk about exchanges and consumer outreach programs.

          This is the false dichotomy between letting consumers fail in the free market vs helping consumers make better decisions. Both remain consistent within the free market orthodoxy however, and it’s the free market itself that needs to be challenged.”

          Spot on. “Giving people the tools to be successful” or some such, is one of the most annoying Democrat/Obama verbal tics. As if it (healthcare, education, you-name-it) is a information processing problem. All us losers need is the correct information (Branding) to turn our lives around. Democrats see everything as a branding problem.

          It seems impossible to deny that free market orthodoxy is the religion of our times, and that we are living through another dark age.

    3. TimR

      Banger, this seems way off to me. You’ve even talked about living in a red state yourself, talking to people and seeing that they’re well-meaning even if you oppose them ideologically. Republicans precisely *do* have a dogma that justifies their policies and claims they are for the best, for everyone. I’m sure I don’t have to re-hash it, everyone knows the doctrine… Baffling that you would say they want people to suffer, to die — maybe some few somewhere (or at least they don’t *care* if that happens) but most believe the dogma… Or if they’re non-ideological people, they’re just on “team red” and it doesn’t matter either way, they could be clueless Dems.

    4. Benedict@Large

      It isn’t at all that the opposition doesn’t point this out; they do so all the time. What’s happening is that the media simply won’t carry this portrayal of the people who control half of the campaign finance dollars. It’s all about money, and the people who are dying don’t have any. Better for the media to cater to those who do, even at the cost of human lives. God save the bottom line.

  5. Brooklin Bridge

    It’s the Supreme Joke, in an amazing corporate friendly contortion of logic, that decided that individuals can be mandated by the government to hand over monthly rent to private corporations for what functionally amounts to nada, zero, zip in return (other than guaranteed bankruptcy) but states, on the other hand, can opt in our out of something that does not have direct benefit to those same corporations, no? As Obummer had it, states were required to expand medicaid coverage, so if there is indeed benefit to it, then the scoundrel should at least get that bone for letting something of value slip through.

    What confuses me is the scenario where the government can confiscate your estate/possessions at the time you finally keel over from the abuse and neglect if you were on medicaid. How does that work with this extension? Can the government mandate you to go on medicaid thereby guaranteeing that you will loose whatever meager assets you had managed to collect for your beneficiaries (such as an adult child that can’t fend for him/herself)? In that case, why not simply take possession of all poor people’s property up front? Strip em bare, and then once they have absolutely nothing, declare them lazy dead beats for not planning ahead and being without a pot to pee in and are brand them not worthy of getting medical attention anyway until they can, say, establish a credit score of 900 (out of a possible 850) or higher at all three agencies that toss chicken bones – or the like – on the ground to determine those scores?

    1. sleepy

      That clawback feature is mandated by medicaid law, but is couched in general terms which have given individual states some leeway.

      Most states use the feature to seize the family home to recover long-term nursing home costs. Other states have used the law to recover expenses for other medical care.

      I believe Michigan is/was one of the worst about this. I don’t have the link handy, bu there was a recent story about Michigan and the outsourced private collection agencies it was using to recover assets from medicaid beneficiaries.

      1. sleepy

        I should add that, at least for long term nursing care, states generally require a signed acknowledgment from the beneficiary that the state can ultimately seize your assets.

        For Obamacare automatic medicaid enrollees, I’ve got a hunch that the acknowledgement business was ignored.

  6. evil is evil

    I have no idea why someone has not gotten pictures of the governors of every state that has rejected medicaid expansion. Put them on a single sheet. Then label them “Death panel.”

    1. Walter Map

      Pubs are great believers in culling the herds of excess livestock, thereby relieving the master class the expense of maintaining unproductive assets. It’s a tribute to modern techniques of social control that large numbers of their victims will actually vote for them.

      Right-wing sheeple: “Baa-aa.”

  7. Dan Lynch

    I have a technical beef with those who claim lack of health care causes “X” number of deaths — we are all going to die. The number of deaths will ultimately be one per person, period.

    It would be more accurate to talk about life expectancy, quality of life, and bankruptcies.

    As for blaming the Republican governors, whose idea was it to delegate health care to the states? The states have a legitimate concern that they will eventually have to bear part of the cost of the ACA. And where do states get their revenues ? From regressive taxes on the poor and the working class. So ultimately the poor and the working class will have to pay for expanded Medicaid so that they can have their meager assets seized.

    Rather than chiding Republicans for opting out of this toxic legislation, we should be calling for free public health care, fully funded and administered by the Federal government.

    1. TimR

      Agree, the states have a legit concern, and like I said above, this lady seemed to be spinning the numbers, or at least was not forthcoming.

    2. Jim in SC

      I agree. Our expanded average life spans have been primarily due to improved public sanitation, the development of antibiotics, vaccines, and the like, all of which are cheap.

      The poor do not use health care in the same way that the middle class does. They go to the emergency room if they have minor problems, even if all signs are that the doctor cannot do anything to help. It’s just the culture. I think Obamacare will eventually be repealed because it will be too expensive.

      The coverage that is available through medicaid, just like the coverage available through the ACA, is not the coverage that we remember from the ’70s and ’80s from private physicians. Doctors are now part of a machine. They can’t spend much time with you. The younger doctors are inadequately prepared because of restrictions on the amount of time they can spend in residency, particularly in surgical specialties. No one is interested in paying for an appropriate amount of residency. They’ll be learning on the public, but the public will be unaware.

  8. marym

    Medicaid is increasingly administered by private for-profit managed care organizations. In Illinois insurance companies opposed an attempt at Republican push-back of the decision by the Democratic governor and legislature to implement the expansion. In some states Republican governors received concessions from HHS for further privatization as a condition for accepting the expansion. In the remaining states it would be interesting to know if there’s any indication that insurance companies lost a fight, or didn’t fight because they didn’t see a desirable market, or whether this was only a political decision by governors and legislatures, without any pressure from potential profiteers.

  9. Paul Tioxon

    Here is a quick overview of the futility of not expanding Medicaid. Medicaid has expanded universally throughout the US. Everyone is paying more in payroll taxes and other fees to fund its expansion. It is universally taxed for, but since the assholes in the republican party want to shove it up Obama’s ass and the poor people who voted for him, especially African-Americans, they sued in court and the stacked Supreme Court of right wing fanatics halted the universal implementation by allowing states to opt out or even seriously modify Medicaid to suit some free market political faction.

    What’s note worthy about the ACA is that its biggest impact is not for the private insurance for people who have trouble getting or affording private insurance. It’s biggest impact is on the poor, working or non-working, who have no insurance, had no insurance and would likely continue on that path to death in even greater numbers. With numbers of uninsured ranging from 30-40 million or more, the 5 million or so working who buy private insurance to comply with the ACA is obviously not the the overwhelming policy thrust, but a small potatoes portion of trying to rein in health care costs while also providing health care access on a wider basis.

    This is a mixed economy, and despite the obvious policy of single payer universal coverage as the only rational course, and most likely, the only eventual outcome in most of our lifetimes, a mixed economy is the direct result of diametrically opposed political blocks that can’t wipe the other out off the face of the earth with ease. By covering most of the poor or the lowest 20% of the income stratification of the nation, the long term health cost should begin to be suppressed as more and more people see a doctor before they have succumbed to expensive chronic degenerative disease management. That is what the Medicaid expansion was supposed to do. The idiotic legal attack and schizo court decision did not stop the full taxation across all 50 states, it only suppressed by political whim the implementation of Medicaid through the random process of electoral results with republican controlling state majorities, for the most part. New Jersey being a mix of republican governor and dem state house was an exception. Pennsylvania with total republican control by chance during the ACA rollout, has lost out, but may opt in by next year with a dem governor.

    Policy implementation, getting everyone in America covered with doctors and hospital care as medically needed, is a long term process being squeezed out into our mixed political-economy. The consumer complaints about the website, the price increases, the canceled policies, the foul ups, lost applications, on and on is part and parcel of everyday life of Americans in all other areas of their lives, especially when dealing with HMOs, PPOs and other insurance claims. These are complaints about defective products and services of an immediate nature. Polilcy on the other hand plays out over a longer period of time. Secular trends and consumer services are distinctly not to be conflated.

    Medicare Part D, for example, is quasi-mandatory. But, you have to decide to voluntarily sign up for it. A few years back, they changed the law so that if at any point in the future, you bought into any kind of Medicare Advantage plan, but did not have Part D along with your Part A&B, you would be fined and have to pay a monthly fee in addition to yr premiums. It it not mandatory, but you will be fined in the future and have to pay the fine if you opt into any kind of Part D or Advantage without previously signing up for some sort of prescription from anyone anywhere subject to their approval. Medicare Part D, the prescription plan is not a smooth implementation with a little tweaking to get it just perfect. It is not close to being acceptable. It is confusing and misleading to this day. If there is to be Medicare for all, they need to make a simple plan of 100% cost coverage, not 80% and include all other medically necessary services from dental, vision, prescriptions and pharmacy devices and supplies, therapies, etc. It is too complex and too attenuated, falling far short of comprehensive medicine.

    For the most part, the complaining about the Obamacare roll out only proves Woody Allen to be the sage of the Hollywood one liners:”..After all, you know, there are worse things in life than death. I mean, if you’ve ever spent an evening with an insurance salesman, you know exactly what I mean. The key here, I think, is to… to not think of death as an end, but think of it more as a very effective way of cutting down on your expenses.” ….. LOVE AND DEATH.

  10. Oregoncharles

    Isn’t this, too, a failure of the bill itself? Republicans’ refusal to co-operate was foreseeable, yet there’s no provision for it.
    This is a GENERAL characteristic of the ACA. To operate as intended, it depends on the co-operation of various parties who are not required to: Republican state governments, the insurance companies, even the famous “young invincibles”. Hence not only this problem, which leaves a large group of poor people with no help, but also the wave of extremely embarrassing cancellations and the worry about the demographic of those who sign up.
    Yes, people are “required” to sign up; but the initial penalty is trivial compared to the cost of insurance, and some of these are people who already calculated that it isn’t worth it. At best they’ll wait till the penalties are higher; at worst they’ll arrange to have no refund, then thumb their noses at the system.
    And at the very worst, there’ll be a movement of civil resistance to the Mandate.
    The ACA is a botch in many ways, but surely these weird vulnerabilities are its worst feature, at least from a political point of view.

    1. Code Name D

      But this is central to “market based reforms”. This is not a flaw or an oversight, but a feature. The cooperation of the insurance companies is entirely contingent on them making larger profits than before. There was a profit motive for canceling those policies, regardless of weather they were or were not in compliance with the new rules. The only people who don’t have any choice – are the consumers.

  11. chicagogal

    Let’s not forget that those in states that accepted the increase in their Medicaid rolls will have numerous problems with doctors, hospitals, etc. that refuse to accept Medicaid. Pushing millions of people into that system is just as cruel as those states who refused Medicaid through the ACA.

  12. washunate

    It takes two to tango…

    That Medicaid expansion is the most liberal part of PPACA shows how terrible the Democratic effort generally, and the Obama Administration in particular, was and remains on healthcare. It is not a statement about how great Medicaid is.

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