As noted on Friday, Tom Corbett’s expected announcement this afternoon that Pennsylvania would sorta kinda with a waiver accept vast federal funds for expanding something like Medicaid eligibility means that a majority of states have at least sorta kinda gone along with the expansion.
This seems to be an occasion for celebration in some circles. But for the record, when SCOTUS made the Medicaid expansion optional for the states, the CW was that all the states would go along. I objected to that consensus on the day of the decision in a TNR column, and then assessed other reactions the next day here at PA:
I remain about the only member of the chattering classes willing to predict the Medicaid expansion could be in trouble, at least in the South, where it matters most…..
So far no governor has come right out and said they’d fight the Medicaid expansion now that the Court has made that action possible at the cost of something less than complete withdrawal from Medicaid (Kaiser Health News has compiled a list of quick reactions from the states on this subject, which includes some saber-rattling from GOP leaders, including one definitive prediction of resistance from a Missouri legislator). But I continue to think it’s just a matter of time until that becomes a realistic possibility. In some states it will involve a battle not only between Democrats and Republicans, but between conservative ideologues and the health care interest groups (e.g., hospitals, medical equipment vendors, private insurance companies with Medicaid delivery contracts) in a position of influence with the GOP.
I’d say implementation of ACA remains pretty strictly contingent on the November elections. If Republicans win the White House and control of both Houses of Congress (and the two outcomes remain likely to be linked), the odds are high they would attempt a total (or near-total) repeal of ACA in the context of enacting a Ryan Budget that would, of course, radically reverse progress towards universal health coverage far beyond where we were in 2010. If they lose in November, or (for the sake of argument) fail to get control of the Senate, then the big question is whether an enraged conservative movement begins looking for other options for mucking up ACA implementation, at which point demands on Republican state lawmakers to block the Medicaid expansion will be ratcheted up to a high-pitch chattering whine.
That seems a pretty acute prophecy, if I say so myself. I bring it up not to boast, but to warn that today’s happy-making over the progress of the Medicaid expansion is to some respects as questionable as yesterday’s. A lot of these brave GOP governors who are going along with a coverage expansion are doing so for a price: HHS cooperation with major privatization efforts in Medicaid. I’m not saying HHS is making the wrong call here; any kind of coverage is much better than none, and there’s nothing sacred about “traditional” Medicaid, which has already been vitiated in many states in favor of various privatized models. But the fact remains that the number of Republican-controlled states that have actually accepted the original Medicaid expansion deal is very small–Arizona, New Mexico, North Dakota and maybe New Jersey (though last time I checked, Chris Christie had vetoed legislation simply accepting the expansion and was preparing his own ill-defined plan). That’s important in itself, and also serves as a reminder that predicting that today’s GOP lawmakers will behave rationally is at best a dubious proposition.