The Consequences of Some States’ Rejection of Medicaid Expansion

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November 22, 2013; Washington Post

An article about differences among Republican governors concerning states’ decisions whether to expand Medicaid coverage for adults with incomes up to 138 percent of the federal poverty level, in terms of how it might affect the presidential aspirations of Chris Christie of New Jersey, John Kasich of Ohio, and Bobby Jindal of Louisiana, among others, prompts us to think about the underlying issue. Trying to sidestep an outright pre-2016 attack on Christie in particular, Jindal and Mike Pence of Indiana, both opposed to Medicaid expansion, drew on similar conceptual frameworks to explain their decision-making processes:

  • Pence: Whether or not to follow the Affordable Care Act’s provisions for expanding Medicaid coverage “was a decision that every governor had to make based upon the unique circumstances in their own state.”
  • Jindal: “Every governor has to make the best decision for their state, so I’ve never second-guessed or criticized or questioned those governors who made a different decision than I did.”

According to Reid Wilson of the Post, Christie said that Medicaid expansion in New Jersey would make healthcare coverage available for 104,000 residents and save the state $229 million in the first year. What are the “unique circumstances of their own states” that would have made the other Republican governors mentioned in the article opt against Medicaid expansion?

Nikki Haley’s South Carolina: Current state policy caps Medicaid coverage eligibility for adults with dependent children at an annual income of 67 percent of the federal poverty level, $13,085. That means that 194,330 poor non-elderly adults in South Carolina fall into the “coverage gap” of having incomes too high for the state’s Medicaid coverage but below the limit to qualify for healthcare insurance tax credits on the state or federal exchanges.

Bobby Jindal’s Louisiana: Louisiana caps eligibility at 24 percent of the federal poverty level or $4,685. Almost a quarter-million Louisianans, 242,150 to be exact, are in the ACA coverage gap because of the state’s failure to expand Medicaid coverage.

Rick Perry’s Texas: In Texas, the eligibility limit is 19 percent of the federal poverty level, equivalent to an income of $3,737. It is hard to fathom, but Texas’s decision against Medicaid expansion leaves 1,046,430 poor Texans in the coverage gap, constituting more than one out of five poor elderly adults in the nation—22 percent—in the gap.

The Washington Post article was on the politics of these decisions, as opposed to the social cost. It quoted Senator Rand Paul (R-KY), no friend of Christie’s and a potential Republican primary opponent, explaining his opposition to the Medicaid expansion. “On the case of the New Jersey governor, I think embracing Obamacare [and] expanding Medicaid in his state is very expensive and not fiscally conservative,” Senator Paul said on CNN. “That fact, I would say, would lead towards you making the conclusion that it’s not a very conservative proposal.”

The Post’s Wilson noted that political strategists said that “the negative television advertisements against Christie and Kasich on Medicaid virtually write themselves,” due to their decisions in favor of expanding Medicaid coverage.

Perhaps in the extreme politics of Republican opposition to anything and everything associated with the Affordable Care Act, the decision to extend healthcare coverage to the poor constitutes a primary election candidacy-killer. Tell that to the 4.8 million people nationwide who, including the numbers of Texans, Louisianans, and South Carolinians in this article, won’t have Medicaid, are too young for Medicare, but are too low income to qualify for federal subsidies to purchase private healthcare insurance on the exchanges. Senator Rand’s political analysis will mean nothing when that poor family has to wait in an emergency room for treatment because of the lack of Medicaid and private insurance.—Rick Cohen