The endgame arguments on expanding Medicaid

With just nine months remaining before the mostly complete implementation of the Affordable Care Act, the debate and political maneuvering has reached its endgame.

How the ACA will appear in January 2014 is now boiling down to the actions of state Legislatures. They are grappling with whether or not to expand Medicaid coverage--an option last year's Supreme Court ruling upholding the constitutionality of the healthcare reform law provided.

The ACA is one of the most controversial pieces of legislation of the past half century, and it is therefore no surprise that its opponents are changing tactics as swiftly as you can reverse the polarity on an electromagnet.

Witness the debate earlier this week in the Iowa Legislature, which I believe is a reflection of the current arguments around the country.

The Senate, which is narrowly held by Democrats, voted to expand Medicaid mostly along party lines earlier this week.

The Democratic lawmakers were consistent in their arguments of support: Many cited affidavits from hospitals and healthcare systems operating in their district that do not want to continue seeing their emergency rooms flooded with patients.

"We talk about the uninsured, we talk about the working poor ... those are my patients," said Sen. Chris Brase, whose day job is a paramedic/firefighter in Muscatine, a town of 23,000 a few miles west of the Illinois border. Brase added that many locals do not want to be taken to a hospital emergency room because they cannot afford it.

For much of the three years since the ACA was signed into law, the argument has been against government meddling in the ability of Americans to make healthcare decisions--remember so-called death panels? Now, ACA's opponents have embraced the opposing argument: The federal government won't actually support Medicaid expansion.

That was the warning from Iowa Sen. Jack Whitver, a Republican who represents a suburb of Des Moines. He believes the feds will shirk their promise of fully funding Medicaid expansion from 2014 through 2016, and 90 percent in the future years.

Whitver cited two other federal programs--one that provides education funding for disabled children and another that provides funding to local jurisdictions for the costs of jailing undocumented immigrants. Both were supposed to be 40 percent funded by the federal government, but the current levels of funding don't even break 20 percent.

"'Paid for' means the federal government has the money--not print the money or, worse, borrow the money and put that debt on the backs of our kids," Whitver said. He conveniently sidestepped the fact that government programs can be paid for by raising revenues, whereas a medical bankruptcy filing by the parents of one of those kids would likely hamper their ability to pay for college or otherwise brighten their futures far more than adding to the federal deficit.

Whitver also neglected to mention that the lobbies for disabled children and local law enforcement agencies pale in comparison to the state hospital associations, the American Hospital Association and the Federation of American Hospitals. Should Medicaid funding shrink, you betcha Congress would hear from them.

The Iowa House of Representatives has yet to vote, but it is controlled by Republicans. 

And Gov. Terry Branstad, also a Republican, is opposed to expanding Medicaid eligibility to the 138 percent of the Federal Poverty Level permitted under the ACA. Instead, he's pushing Healthy Iowa, an alternative program that would keep eligibility at 100 percent of the Federal Poverty Level and include only a handful of the state's approximately 100 hospitals.

Similar dramas are playing out in Texas, Florida and several other states. If they opt out of Medicaid expansion, they all risk the same scenarios: Nightmarish news stories focused on families who would have qualified for Medicaid going bust, out-migration of their younger residents into other states to obtain coverage, and relentless pressure from hospitals and other providers.

As a matter of fact, the whole ACA endgame debate was succinctly summed up by Whitver in his closing remarks on the Senate floor.

"We're not arguing (Medicaid expansion) helps people," he concluded. "We're arguing whether it's sustainable to help people."

I'd like to think there's still someone in this country who thinks helping people is self-sustaining. And I would hope leaders in those states still on the ACA fence will figure that out. - Ron (@FierceHealth)

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