What would the Founding Fathers say about Medicaid expansion?

When the Florida Legislature voted down Medicaid expansion yet once again last week, I received a glowing announcement from the James Madison Institute, a Tallahassee-based think tank that has a lot of influence in shaping Sunshine State policy.

"Now it is time to come together to start chipping away at the many proposed solutions that will lower the cost of healthcare, increase access to healthcare services and improve health outcomes for all Floridians," the announcement said, quoting Executive Director Bob McClure.

I would presume McClure means chipping away at expanding Medicaid, which he has been adamantly against. Either that, or he needs a better grammarian writing his quotes.

I do know that the state's hospitals feel like they're being chipped away at, knowing the Obama administration has run out of patience with Gov. Rick Scott's flip-flopping on the issue and the intransigence of its statehouse. Lawmakers will likely pull funding later this month for the Low Income Pool program, removing billions of dollars that could help care for the state's impoverished residents.

But according to the JMI--which has posted 25 reasons not to expand the Medicaid program on its website--it's just doing its job. JMI says the essence of its mission is "to keep Floridians informed about their government and to advance practical public policy solutions ... James Madison, we believe, would have approved and no name could better suit the Institute."

The JMI also claims it's non-partisan, even though McClure was a Jeb Bush appointee to the Florida Elections Commission and was an adviser to Scott and state Attorney General Pam Bondi. Another member of the JMI staff helped found Tallahassee's Tea Party chapter and co-authored a rather notorious 2008 book claiming that Barack Obama would throw away the Constitution if elected.

But it is the institute's self-cloaking in the James Madison legacy that has piqued my interest. Madison is perhaps best known for co-authoring the Federalist Papers, which provide a blueprint as to how the U.S. Constitution was intended to function. Federalist Paper #10 is at the crux of how Madison perceived the Constitution's primary purpose: To avoid factionalism, which leads to passions that tend to oppress the rights of the minority. According to Madison, "the most common and durable source of factions has been the various and unequal distribution of property. Those who hold and those who are without property have ever formed distinct interests in society."

I like to give the benefit of the doubt as a journalist, so I'm not going to express my opinion as to which side of the property equation the JMI's board of directors falls on. Although they are utility CEOs, land developers, cable channel owners, high-level financial advisers and partners in law firms, it is possible they have very humble lifestyles in the tradition of Founding Father Ben Franklin.

I will concede they are a pretty pure physical reflection of the Founding Fathers, in that they're all white males and rather appropriately north of 21 years of age.

Whether the JMI strives to protect the minority is less clear. In 2009, it issued a paper essentially arguing against donating any money to philanthropies that strived for more diversity in their leadership. I do credit the JMI for being extraordinarily consistent in maintaining this belief regarding both its directors and staff.

I also credit the JMI for making a proposal for expanding healthcare to the poor: Have them purchase health savings accounts. That and some expansion of telemedicine and price transparency. No mention as to how the poor could pay for this stuff out of pocket.

Meanwhile, the issues of factionalism and protecting the rights of the minority remain on the table. Madison argued that's where the federal government plays its biggest role, by regulating the behavior of the states from some remove.

That's essentially what's going on with Medicaid expansion: The federal government is intervening in a way intended to help one faction, the poor, not be oppressed by illness and endless medical bills. They are colliding with another faction, which believes helping the poor will just continue a cycle of making them shiftless and lazy (that this is the JMI's reason No. 25 not to expand Medicaid is merely a coincidence).

In Madison's world, the legislator is supposed to be dispassionate and do the right thing. But in his day, there were no PACs dispensing millions of dubloons to get them elected or defeated, or a John Bunyan Institute or a Jonathan Edwards Society exploiting the righteous images of their namesakes to disguise baldly partisan intentions.

Actually, given the state of healthcare delivery in colonial times, I imagine Madison and the other Founding Fathers would have been fairly delighted if they could ensure everyone had an equal shot at not dropping dead in childhood. My guess is they would have expanded Medicaid. -- Ron (@FierceHealth)

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