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Thursday, October 27, 2016

Oct. 13 (Bloomberg View) — A spurt of Republican states changing their minds on Medicaid expansion backs up an optimistic argument you hear a lot in health-policy circles: It took a long time for all 50 states to sign up for the original Medicaid program, and the expansion will unfold in the same way — slowly but surely.

If the analogy holds, the takeaway is not to get too concerned about Medicaid expansion: Even the reddest states can only deny federal money to their hospitals, doctors and insurers for so long, which means that poorer Americans in every state will get coverage eventually. The federal government should keep doing what it’s doing — offering compromises, and letting pressure from state lobbying groups do the rest.

But interviews with hospital and insurer associations in states that have yet to expand Medicaid suggest that “eventually” could be a lot longer this time around. If so, the federal government might need a change in tack, as it tries to extend coverage to almost 5 million people.

One problem with looking at Medicaid’s initial adoption is that it can exaggerate how long the program took to catch on in most states. Yes, Arizona waited 16 years to sign up. But the state was an outlier. Thirty-seven states had signed up within the first two years of the program; by the beginning of 1970, just four years after Medicaid started, every state but two — including every state in the South — and Washington, D.C., was taking part.

The 1960s analogy also misses the headwinds Medicaid faces today. The Obamacare expansion started with a rush equal to 1966, with 26 states plus the District of Columbia signing up so far this year, and Pennsylvania set to expand in January. Indiana has submitted a plan, and governors in Utah and Tennessee have talked about applying, too.

But it’s not clear how many of those states’ legislatures will agree, or how many other Republican-led states will follow. And absent a Democratic sweep of statehouses next month, it’s hard to see a second-year wave of a similar magnitude to 50 years ago. In the South, where opposition to expansion seems most entrenched, it’s uncertain whether advocates are making any progress at all.

Take South Carolina, where expanding Medicaid could reduce the number of people without health insurance by one-third. The state waited two-and-a-half years before joining the original Medicaid program. This time around, even that time frame looks optimistic: Jim Ritchie, who runs the state’s association of health plans, said he doesn’t expect any movement until at least 2017.

Rozalynn Goodwin, vice president for community engagement at the South Carolina Hospital Association, suggests a leading indicator for expansion: Out of four crucial groups — hospitals, health insurers, doctors and chambers of commerce — how many have publicly come out in support?

South Carolina is still one for four; even its state medical association won’t back expansion. But at least its hospitals are on board. In Mississippi, even hospitals are reluctant to push for expansion, according to Roy Mitchell, who runs the Mississippi Health Advocacy Program.

“That’s really something that perplexes us,” Mitchell told me, noting that hospitals stand to gain significant revenue if the state says yes. In red states that agreed to take the federal money, he noted, “the provider community were the fiercest advocates for expansion.”

(A spokeswoman for the Mississippi Hospital Association, Shawn Rossi, told me nobody was available to talk. Hospital associations in Georgia, Alabama and Louisiana didn’t respond to repeated requests for comment.)

Not taking a position is one thing. In Alabama, Michael O’Malley, the head of the state’s association of health plans, is openly opposed to expansion — even though, if the state copied the model of nearby Arkansas, where federal dollars are used to buy private insurance, it could mean new business for Alabama insurers.

“I agree, and I think my members agree, that [Governor Robert] Bentley is doing the right thing” by saying no, O’Malley said. In its current form, “expanding Medicaid makes zero sense for Alabama.”

By contrast, insurers in Louisiana, which signed up for Medicaid the first year it could, aren’t hostile to expansion — they just don’t see any point in pushing it. I asked Jeff Drozda, head of the Louisiana Association of Health Plans, why his members hadn’t taken a public position on the expansion, even though it would benefit them. Here’s what he said:

The plans need to make a strategic business decision on whether or not they would want to go out in the public forum like that. Realistically, they realize that it’s a state where both the House and the Senate, and the governor, are pretty much on the same page of not being interested in moving toward expansion this year or next year. It doesn’t benefit anyone to go out there and make those comments if it’s not going to happen anyway.

Of the states I looked at, the only one where I could find even a whiff of optimism was Texas, which signed up for Medicaid the year after it became available but shows no such interest in expansion.

“There’s a slight opening” among some legislators, Lance Lunsford, spokesman for the Texas Hospital Association, told me. But he said you would never know it, because admitting as much is political suicide. It’s fine to talk about the financial benefits of expansion, Lunsford said, until “you realize you’re talking to yourself in a room with the door closed.”

The picture presented by these states isn’t one of commercial interests gradually chipping away at ideological opposition to expansion. Rather, it’s one of a political reality so entrenched that those commercial interests either can’t make headway or don’t bother trying.

Of course, like anything in politics, that can change. But if it doesn’t, Democrats in Congress will need to decide how important it is to fix this, and then consider authorizing still sweeter deals — 100 percent federal funding, perhaps. Or they could expand coverage through other means, for example by making more people eligible for federal subsidies on the state insurance exchanges.­­­

Those seem like improbable solutions right now, especially with Democratic control of the House out of reach until at least 2016. But if the wait-it-out analogy with the 1960s proves to be wrong, then at some point it’s worth looking at alternatives — or admitting that for some states, eventually could mean never.

AFP Photo/Mandel Ngan

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  • MollyBee64

    Terrible leaders deny health care to millions. What do you expect from people who consider corporations, “people”. The GOP needs a lot of hot air knocked out of their sails this November.

  • Dominick Vila

    The MEDICAID expansion, a key component for the success of the Affordable Care Act, will not become reality nation wide until President Obama leaves office. When he does, the GOP will take credit for changes to Obamacare designed to reject facets of evil socialism, will adopt the program as their own, and the problems the ACA is still having as a result of partisan obstinacy will fade away.
    The same thing is happening with the GOP claim that our economic improvements and job creation record are false. Embattled Republican Governors, such as Rick Scott in Florida, is highlighting the high unemployment rate that existed 4 years ago, and is taking credit for the low unemployment rate that exists today. The usual claims of part time or temporary jobs, or the need to use different methods to determine unemployment, are conspicuous by their absence…when there is a wedge to benefit from what they demonized a few weeks ago.

    • Jambi

      Dominick – I agree with you whole-heartedly…The GOP will try and take credit for many Obama administrative successes (which they criticized earlier)…long after our President has left office…

      • Dominick Vila

        This is far from being unprecedented. They don’t hesitate to take credit for President Clinton’s economic successes, and don’t hesitate to blame him for 9/11 since 8 months was, in their opinion, not enough time to understand the Al Qaeda threat and alert our law enforcement agencies of an impending attack on U.S. soil.

    • Taz202

      Unfortunately, this is the sad truth. The GOP cares nothing for the people who are affected by lack of health insurance coverage. They care only about their political careers…period!

      • jmprint

        I love quoting Ted Cruz, because he is such an idiot. “If you can’t afford insurance, get a better job.”

      • Allan Richardson

        The Priest and the Levite (establishment politicians and the religious right) passed by on the other side of the road, and only the Samaritan (leftist liberal commie Muslim N-loving gay … ) stopped to help the injured man.

  • howa4x

    There is politics and then there is reality. Hospital/doctor associations may live in fear of 1 party rule but going under financially is another issue. 8 rural hospital is Georgia have already closed their doors and more will follow all across the south. This will have a disastrous effect on supply chains. Everything from food service companies to durable medical supply companies will suffer an economic downturn and layoffs will result. It is a ripple effect. Also lets take Ebola for instance as an issue for who pays the bills. Texas leads the country with 1/4 of the population uninsured. What if some of those people get Ebola? They need round the clock intensive care by teams of specialized medical personal. Each one may go through 10 protective suits /day. If it is an uninsured patient who will cover that cost? Let’s play this out to a major flu pandemic which is much more likely. Who will pay for the4 hospitalization of thousands of the uninsured? Who will pay the 5-7 k /day, cost of quarantine? Those states for ideological reasons that didn’t take the Medicaid expansion will bore the costs themselves, and so will their taxpayers

  • charles king

    I think the American Public better start checking out How? their country is being governing cause there is no reason in the world Why? the people of these United States do not have a reliable cost free health system. These so call Anti big Govt. are a bunch of greedy capitalistic Pigs Who? has taken over the Republican Party. I have been around a long time so let me tell you What? works in America. Social Security works, Democracy works, Obamacare works, Public Education works, Unions work, J A Z Z works so dont let Whoever? they are play games just go with What? works for you. Critical Thinking works so get busy and help yourself cause you are the one Who? can make it happen. Thank You are the magic words in my book. I Love Ya All. Mr. C. E. KING

  • pmbalele

    Did you hear this? Ebola spread
    is result of TPs and Repubs in Congress that cut funding for Ebola vaccine
    research just to save on deficit in 2011. Now this Nation is in horrible danger
    that some people, especially the poor will die of Ebola caused by TPs and Repubs
    selfishness for cutting research. I am
    still told some people still want to vote for TPs and Repubs back in Congress
    and senate when you now know these don’t care for safety of people this nation.
    TPs and Repubs are monsters.

  • R & E Alexander

    Entrepreneurs by R. Alexander Ph.D.

    Texans will go through their election cycle, “1st Tuesday after the 1st Monday in November”, or in 19 days. Another governor will prepare to take office.

    Yet, something still matters in the case of Rick Perry and his “naming ritual” cover-up. What is the reason for his and his wife’s participation in the naming ritual of their two children, Griffin and Sydney?

    1) in that they named them after the family of Albert Sidney Johnston, a Confederate General killed at Battle of Shiloh, 6APR1862.

    2) in that they understood the fact that Johnston collaborated and directly gave assistance to enemies of the national government during War and collateralized oppression of forced laborers.

    3) in that they manifested outward dislike to presidential contender Willard Romney during the 2012 national elections, indicating consonance with Johnston, who was a Union Colonel during the Utah War 1857-58 (the Mormon War).

    4) in that they knew that Johnston’s second wife, Eliza, a cousin of his first wife, had a son named Griffin.

    5) in that they knew the family settled at China Grove, part of a garrisoned agricultural system (GAS) in Brazoria County, following the Spanish empresario movement of the early 1820’s and the opening of Mexican territory to Anglo-American colonization.

    6) in that they know that the “entrepreneur” movement has found new life in Perry’s descent upon other cities throughout the United States and abroad!

    We need warning, and this includes Texans, about specific forms of “economic relationships”. Especially, as Pablo González Casanova explained in his book “Democracy in Mexico” in Chapter 2 “The Factors of Power”, under the sub-title “The Entrepreneurs”, “… the types of social relationships which some scholars equate with feudalism.”

    Moreover, Greg Abbott, the Republican candidate for governor, often sites the value of “entrepreneurial” qualities when meeting with women!

    Concluding point: Shouldn’t Texans have known about the Perry’s proclivity toward identifying with combative enemies of the U.S. Government and feudalistic economic policies?

    Remember the concern given to voting rights: some persons can not vote due to (1) total mental incapacity; or (2) partial mental incapacity. Texans need to know the cause for voter’s impairment (confusion) and the conditions in which interested groups can mitigate decisional impairments through investigative and open press venues.

    Pablo González Casanova. Democracy in Mexico. (London: Oxford University Press, 1972), p. 48.