Medicaid Expansion: We’ve Been Here Before

For those (like me) with a pessimistic view on the willingness of Republican governors to stop lying to themselves and their citizens about the fiscal–not to mention moral–case for implementing the Medicaid expansion authorized by the Affordable Care Act, a history lesson is in order. States have faced this sort of decision before–when Medicaid was first established, and when the Childrens’ Health Insurance Program–better known as CHIP–was set up a generation later. And there was plenty of resistance in both cases, as Sarah Kliff explains at Wonkblog today:

Medicaid got a chilly reception when it launched in January 1966. It was up to the states to decide whether to participate and only six initially signed up: Hawaii, Illinois, Minnesota, North Dakota, Oklahoma and Pennsylvania. Twenty-seven followed suit later that year. Across the country, governors weighed the boon of new federal dollars — Washington would foot half of Medicaid’s bill — against the drawback of putting state money into a new program….

Over time, however, the lure of federal dollars proved strong enough to win over resistant states. Eleven joined the program in 1967. Another wave of eight, largely Southern states came on board in 1970. Arizona proved the last holdout, not joining Medicaid until 1982.

CHIP was the most dramatic of a number of efforts by Congress to build from Medicaid by offering states a better match rate:

States would have to pay about 35 percent of the program’s bill. That was a better match that Medicaid’s regular contribution of 50 percent, but still left states with some financial responsibility – and a commitment to participate in a new government program.

That made CHIP a subject of heated debate in Texas, where the Democratic-controlled legislature clashed with then-Gov. George W. Bush over whether to participate.

“States like Texas sat on the opportunity for a while,” said Jason Cooke, who served as Texas’ first CHIP director. “The governor was not interested in calling a special session to get it authorized and, frankly, didn’t want the CHIP program authorized in the first place.” Texas did eventually enroll, with Bush signing legislation authorizing the program in 2000. By the end of that year, all states had adopted the CHIP program.

ACA’s Medicaid expansion offers a vastly better match rather than CHIP. But then again, if George W. Bush was the epitome of conservative governors in the late 1990s, his protege Rick Perry–who punctuated his presidential announcement speech with a complaint about poor people not paying taxes, and has flirted with secessionist rhetoric–is more typical of the current breed, who find it politic to openly despise the needy as looters and parasites. So while it may be just be a matter of time before the fiscal insanity of turning down ACA’s Medicaid expansion fully sinks in, it may be a long time before the moral calculus changes and it’s no longer fashionable among conservatives to turn a blind eye to the uninsured.

Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.