Medicaid Tipping Point?

The recent decisions of three Republican governors–Jan Brewer of Arizona, John Kasich of Ohio, and Rick Snyer of Michigan–to go along with the Affordable Care Act’s Medicaid expansion provisions has convinced some observers that the states collectively are reaching a “tipping point” where the remaining holdouts will be under terrible pressure to follow. Here’s how WaPo’s Sarah Kliff puts it:

Many Republicans balked at the expansion when the Supreme Court made the Medicaid expansion optional in its ruling last in the summer. Supporters of the law worried that the opposition could undermine the entire health-care overhaul by shrinking the pool of Americans who would gain coverage.

But six Republican governors have since come to back the program, including Michigan Gov. Rick Snyder on Wednesday and Ohio’s John Kasich on Monday. Arizona Gov. Jan Brewer announced her support in mid-January.

It’s an extraodinary turnaround that suggests the lure of federal dollars could halt Republican obstruction of the health-care overhaul. Twenty-two states and the District are now on board, and 17 others are deliberating. The remaining 11, all with Republican governors, have said no — but observers believe the recent decisions could change some minds.

Well, maybe. Naysayers like Rick Perry of Texas, Bobby Jindal of South Carolina, and Nikke Haley of South Carolina have demagogued this issue to a degree that may make backtracking impossible, and all three may well be vastly more interesting in scoring national conservative brownie points than in making any rational cost-benefit calculations. And some Republican governors, notably Mississippi’s Phil Bryant, are morally offended by the idea of Medicaid itself–never mind an expansion.

But the big test case will be Florida’s Rick Scott, who governs a state that trails only Texas in terms of the impact of its decision on the Medicaid expansion (potentially 1.3 million Floridians might qualify).

Scott is being deliberately cadgy about the Medicaid expansion at the moment. He got caught publicly lying about its cost (though he was only off by a bit over 80%, without considering probably state savings from reductions in uncompensated care), and is clearly using the leverage of his indecision to seek extensive Medicaid waivers from HHS Secretary Kathleen Sebelius (including one allowing wholesale transfer of Florida Medicaid beneficiaries into privately-run managed care plans). His recently released budget doesn’t include funds for the Medicaid expansion, but doesn’t close off the possibility of later amendment.

And then there’s the politics. Scott wants to get re-elected in the worst way, and is very unpopular. With polls showing over 60% of Floridians supporting the Medicaid expansion, it may not be the best time for the governor to cut any Tea Party capers.

So this is the state and the Republican governor to watch. But I don’t think the “tipping point” happy-talk is necessarily accurate. Some Republican governors insist this is not a fiscal decision. Indeed, some are perfectly happy to publicly admit they don’t much care about poor and sick people–or that their idea of “caring” is to make sure they get a chance to show “personal responsibility” for sickness and death.

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.