Have to say, it never much occurred to me that the horrifically disappointing record of Republican-controlled states accepting or rejecting the Medicaid expansion element of the Affordable Care Act might start looking like Plan B for Obamacare. But that is what Harold Pollack, one of the smartest and most tenaciously optimistic progressive health care writers, seems to be suggesting at The Nation (of all places!). After arguing that the performance of the Obamacare exchanges is bound to improve, Harold shifts to what lawyers call “arguing in the alternative:”
The final silver lining will be harder to accept for committed activists on both sides of healthcare reform. Many readers might not see this as a silver lining at all. But hear me out. The Obama administration has been chastened by its poor rollout performance. It needs practical and political help from Republicans—not from Republicans in Washington, who have little incentive to collaborate, but from Republican state office-holders who have actual responsibilities to govern who will eventually own their state’s version of healthcare reform.
And Republicans around the country have been chastened by the Tea Party’s politically radioactive decisions to seek concessions over the debt ceiling and to shut down the government. States face powerful incentives to embrace the Medicaid expansion, which is so valuable to both consumers and providers of healthcare. In states such as Ohio, Arizona and Pennsylvania, all of which have Republican governors, we can already see the beginnings of a bipartisan negotiation.
Liberals like me may be disappointed by compromises the White House is likely to make to provide GOP governors with a dignified path to accept Medicaid expansion. Some states wish to impose (modest) co-pays for non-generic drugs or for emergency department use. Others ostensibly maintain the right to opt out of the Medicaid expansion if the federal government lowers its matching rates. Republican governors require such concessions. After all, they have spent the past five years bitterly opposing health reform. Maybe HHS will follow the Arkansas compromise and allow more poor people into exchanges rather than Medicaid in states that request that option.
Well, at the moment, 25 states are implementing the Medicaid expansion; 21 aren’t; and it’s still a possibility in four. I see no particular evidence that the kind of administration “concessions” Harold is talking about is likely to move the needle in the 21 rejectionist states; it’s not like it was any secret, particularly after the Arkansas “deal,” that HHS would accept just about any conceivable restructuring of expanded Medicaid eligibility, or even of the Medicaid program itself, to reach an agreement with Republicans.
So this “silver lining” seems to depend on two ideas (a) the underlying fiscal logic for states of accepting the Medicaid expansion (which led a lot of observers to predict its widespread acceptance from the get-go); and (b) the notion that hard-core conservatism is in some sort of general retreat thanks to the government shutdown fiasco. I guess you could add a third: that the grave injustice of leaving millions of people too “wealthy” for Medicaid yet too poor to obtain Obamacare subsidies will begin to bother Republicans in the states.
Regular readers won’t be surprised to hear that I am extremely dubious about all three of those propositions.
In the meantime, Nation readers who may well be hearing or telling themselves that the massive problems with the Obamacare exchanges reflect the inevitable failure of public health care programs relying on private insurers (thus demonstrating the superiority of the discarded single-payer model) may find it hard to accept that going along with deals that further privatize Medicaid represents a “silver lining” or a Plan B. Indeed, some smart conservatives have suggested that is their own “Plan B” for using Obamacare to eventually produce a seamless health care system of publicly subsidized but privately delivered health insurance for everybody. But with Republicans now largely believing they can smell the collapse of the whole Affordable Care Act, I just don’t think they’re going to be in the mood to move in that direction, even if smart progressives like Harold Pollack are open to compromise.
UPDATE: As early readers know, via the technical error known as “not reading the byline carefully,” I misidentified the author of the Nation piece I am critiquing here as my friend the highly respected health care writer Jonathan Cohn, when it was actually my friend the highly respected health care writer Harold Pollack. Apologies to both, and to readers, for the confusion.