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MEDICAID FOR SOME: A map of expansion states (blue) and non-expansion states (orange) as of January 2018, courtesy - KAISER FAMILY FOUNDATION (CC)


  • MEDICAID FOR SOME: A map of expansion states (blue) and non-expansion states (orange) as of January 2018, courtesy

The Brookings Institute takes a look at states that expanded Medicaid and finds no evidence of regret: “The strong balance of objective evidence indicates that actual costs to states so far from expanding Medicaid are negligible or minor, and that states across the political spectrum do not regret their decisions to expand Medicaid.”

Some highlights from the analysis:

[T]he leading peer-reviewed, academic study on this question documented, based on comprehensive data from the National Association of State Budget Officers that, by 2015, “there were no significant increases in spending from state funds as a result of the expansion.” Although states will start to incur some costs in years following 2015 as their 10 percent funding requirement is phased in, several expert analysts predict that those costs are likely to remain modest, despite increased enrollment.

[E]xpanded Medicaid pays for various costs that states previously were absorbing outside of Medicaid. Accordingly, several credible and expert evaluations (including one in the New England Journal of Medicine) show that states such as Arkansas, Indiana, Kentucky, Louisiana, Michigan, Montana, New Mexico, Ohio, and West Virginia (among others) have actually reduced, not increased, state spending as a result of expansion.

The report also collects and links 18 different scathing critiques of the “absurd” and “highly misleading” analysis offered up by the right-wing propaganda mill Foundation for Government Accountability. FGA likes to peddle the story that expansion states are wailing with regret despite the fact that not a single state has turned back on its decision.

The group has blown a good deal of smoke at Arkansas, presumably targeting it as a right-wing red state with a very high threshold (75 percent approval of the legislature) for keeping the policy in place. As in the other expansion states across the country, FGA’s efforts have failed in Arkansas, and Medicaid expansion remains in place (the Brookings Institute report notes that a number of Republican governors and legislatures have kept the policy in place).

There’s no real mystery about what’s going on here. When the federal government offers an enormous amount of funding to states that drastically reduces the uninsured rate and the uncompensated care bills facing hospitals, that’s a good deal for the states (the first three years were fully paid for by the federal government, and the feds’ share gradually declines but remains at 90 percent in 2020 and beyond). Billions of federal dollars have come into Arkansas. The refusnik states didn’t get that money, and they didn’t get the corresponding drop in uninsured rate.

Opposition to the Medicaid expansion was largely unmoored from the parochial considerations of state legislatures. It was about anti-Obamacare politics; to the extent that it was about policy, it was about the ACA’s enactment of taxes on the wealthy and Medicare reimbursement cuts in order to fund an expansion of the Medicaid program. Whatever you might think of that national policy, once enacted, it was in states’ interest to say yes to the funding. It is no wonder that states wise enough to say yes have no regrets.

Meanwhile, once enacted, the politics swing sharply: It’s one thing to say you hate Obamacare, it’s another thing to kick hundreds of thousands of people off of their health insurance.

The case of Arkansas is telling. The state has an incredibly high threshold for approval and re-authorization, unique in the nation. Since the policy was passed, a Republican governor has been elected, and two wave elections in a row have given Republicans total dominance over both chambers, with some of the largest majorities in the country. A significant number of those Republicans who swept into power ran explicitly on an anti-Medicaid expansion plank and made reversing the policy a central promise of their campaigns. One cannot conjure a more perfect storm for a state to reverse itself on Medicaid expansion. Yet Medicaid expansion in Arkansas persists.

Members of the rump group of diehard aginners have traveled to other states claiming that Arkansas is awash in regret, but there’s simply no evidence that this is true outside of Sen. Bryan King‘s own personal night terrors.

It’s almost like the ACA created a policy structure that made it a very good deal for states to expand Medicaid, despite all the political posturing. The Arkansas legislature gets plenty wrong, but they got this one right.

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No regrets for states that expanded Medicaid