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States' Blights

July 3, 2012

Few battle cries rally Republicans more than the demand for "states' rights." But for today's Party of Lincoln, that ideological bludgeon once used to deny millions of Americans their freedom for the first century of the Republic and ignore their rights in the second has a new purpose. When it comes to helping Americans realize their pursuit of life, liberty and the pursuit of happiness, states' rights now often means the right of states to do nothing at all.
That abdication is on full display in the declarations of Republican governors who might refuse $258 billion in expanded federal Medicaid funding under the Affordable Care Act, money which could help bring health insurance to 9.2 million of their residents. More cruel still, recent history shows that those who would instead charge "states with responsibility" to "make sure that every American has access to good health care" are doomed to fail.

On Monday, an analysis by ThinkProgress found that "ten GOP governors have said definitively that they will not accept the funds, while 19 are still considering other options. Sixteen states, all with Democratic governors, have committed to expanding their programs." Starting in 2014, the Affordable Care will expand Medicaid to families earning up to 133 percent of the federal poverty level (FPL) and provide subsidies to those at up to four times the FPL to purchase insurance in state-based exchanges. But as ThinkProgress lamented:

Not a single Republican governor has pledged to accept the new Medicaid funds and three Democrats are also considering turning down the money. In total, these states would give up $291.4 billion in federal funds and leave 10,297,221 Americans uninsured.

As Ezra Klein explained in the Washington Post, the health care law's Medicaid provision should be "too good to pass up." After all, the federal government will pick up 100 percent of the cost for the first three years and 90 percent for the next five. And as it turns out, this latest example of "red state socialism" is a particularly sweet deal for Republican governors whose constituents will benefit most, thanks in no small part to blue state taxpayers:

To get a sense of what an incredibly, astonishingly, unbelievably good deal that is, consider this: The federal government currently pays 57 percent of Medicaid's costs. States pay the rest. And every state participates.
But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there's no difference for the federal government to pay.

If anything, the Post chart above understates the magnitude of the unfolding health care horror story in Red State America. Two years ago, the Commonwealth Fund released its 2009 state health care scorecard, which measured performance in providing health care access, prevention and treatment, avoidable hospital use, equity across income levels, and healthy lives for residents. Again, while nine of the top 10 performing states voted for Barack Obama in 2008, four of the bottom five (including Arkansas, Mississippi, Oklahoma and Louisiana) and 14 of the last 20 backed John McCain. (That at least is an improvement from the 2007 data, in which all 10 cellar dwellers had voted for George W. Bush three years earlier.)

The "America's Health Rankings" project echoed those findings. And in 2009, another UnitedHealth Group funded study similarly showed that red state residents are the unhealthiest in America. With Vermont topping the list and Mississippi bringing up the rear, Americans would do well to listen to Dr. Howard Dean and not former Governor Haley Barbour when it comes to the health care debate.

In a nutshell, health care is worst precisely where Republicans poll best. Nevertheless, Republican leaders determined to undermine national health care reform seem prepared to just say no to red state residents who need help the most.
Louisiana's Bobby Jindal, who warned the "frightening" Court decision could lead to penalties for those who "refuse to eat tofu," insisted "we're going to do what we can to fight it." In Texas, a spokesman announced that Governor Rick Perry "has no interest in fast-tracking any portion of this bankrupting and overreaching legislation." Rick Scott also said no nearly 1 million Floridians who would gain insurance, proclaiming that "since Florida is legally allowed to opt out, that's the right decision for our citizens." And in South Carolina, Tea Party darling Nikki Haley said of 330,000 potential beneficiaries in her state, "We're not going to shove more South Carolinians into a broken system."
Despite the fact that Washington DC will pick up 93 percent of the cost of the Medicaid expansion between 2014 and 2022, Republicans are talking tough about opting out. And the result, low wages -- will be left out in the cold":

"We are concerned many states will choose not to expand coverage," Bruce Siegel, president of the National Association of Public Hospitals and Health Systems, said Thursday in a statement released following the court's decision. "In the 26 states that participated in the federal lawsuit, more than 27 million people have no insurance," he added, and many of those who would have been eligible for Medicaid in 2014 "might no longer have that option."

They won't have that option, that is, because states that choose to go it alone are almost certain to fail to provide coverage for all of their residents.
Unfortunately, recent history shows that even relatively more affluent states have failed to deliver universal coverage when they try on their own. As Ezra Klein's Washington Post colleague Sarah Kliff pointed out, Washington State's 1990's mandate-less reforms led to skyrocketing premiums and insurers fleeing the state. Writing for the Washington Monthly back in 2007 ("Over Stated"), Klein looked at the grim fates of efforts in California, Hawaii, Washington, Oregon, Tennessee and Illinois. Thanks to their small markets, limited resources, unique populations and unsustainability in the face of recession-induced budget cuts, susceptibility to recessions, he concluded "the laboratories of democracy' can't achieve universal health care":

Letting states continue to take the lead would be disastrous, for one very simple reason: providing health care for all citizens is one of those tasks, like national defense, that the states are simply unequipped to manage on their own. The history of state health reform initiatives (and there's quite a history) is a tale of false hopes and great disappointments. The deck is stacked from the start, and the house--in this case the insurers, the providers, and other agents of the status quo--always wins....Over the years, states have tried programs of many different ideological and economic persuasions. All of them failed, and not because the programs were insufficiently inventive, but because states are structurally incapable of sustaining them.

Among those states, it turns out, is Massachusetts. Mitt Romney's prescriptions to repeal the Affordable Care Act and gut Medicaid funding would have the side effect of killing his own signature health reform of 2006. As the Boston Globe recently documented, President Romney "would probably cripple the Massachusetts health care law":

"It would have been impossible for Massachusetts to do what it did without increased federal Medicaid support,'' said John McDonough, a major architect of the state's health care overhaul law and now director of Harvard University's Center for Public Health Leadership. "What he's proposing is in direct opposition to what he did as governor,'' said Amy Whitcomb Slemmer, executive director of Health Care for All in Massachusetts, citing the Bay State's 98 percent coverage rate, the highest in the nation. "That kind of expansion would not have been possible under a block grant program,'' as Romney has proposed. Block grants give states more flexibility in spending federal money, but restrict funding increases.

(Romney himself admitted as much, acknowledging "The Feds fund half of it, they have from the very beginning.)"
Last month, the Republicans' presidential nominee delivered a major address calling once again for the repeal of "Obamacare" and making a case for a states' rights approach in its place:

What I would do is keep--as we have today--state responsibility for those that are uninsured. You see I believe in the 10th Amendment. I believe the states have responsibility to care for their people in the way they feel best. But to help states care for their own uninsured, I would take the Medicaid dollars that comes with all sorts of strings attached today, send them back to the states along with something known as the DSH money, and let states care for their own people in the way they think best. That--in my view--is the best way to care for the uninsured.
And states will learn from each other, and some will have good experiences and others will not. That's happening even today and states are learning and trying new ways to care for the uninsured. It's important for us in my view to make sure that every American has access to good health care.

No doubt, Romney's words came as music to the ears of Georgia Republican Rep. Paul Broun. After all, it was Broun who took to the House floor just days before its passage to decry the Affordable Care Act that would help so many of his constituents:

"If ObamaCare passes, that free insurance card that's in people's pockets is gonna be as worthless as a Confederate dollar after the War Between the States -- the Great War of Yankee Aggression."

Apparently, the old times there are not forgotten. Sadly, health care is another matter.

One comment on “States' Blights”

  1. WI, NJ, and IA may reverse after the next round of elections; a bunch of the other "Old Deep South" states are probably going to go down this road for a long time.
    We have to watch for the federal waiver to allow Vermont and California to implement single-payer. That is the only future.


Jon Perr
Jon Perr is a technology marketing consultant and product strategist who writes about American politics and public policy.

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