“Almost Awesome In Its Evilness”

At Ten Miles Square today, there’s a post by Harold Pollack featuring excerpts from an interview he did with the renowned health care policy expert from MIT, Jon Gruber. Like a lot of experts (but, for the record, not me), Gruber assumed the Medicaid expansion provided for in the Affordable Care Act would be a no-brainer for the states once the Supreme Court made it optional. So now he assesses the rejectionist states with special scorn:

I’m offended on two levels here. I’m offended because I believe we can help poor people get health insurance, but I’m almost more offended there’s a principle of political economy that basically, if you’d told me, when the Supreme Court decision came down, I said, “It’s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?” The fact that half the states are is such a massive rejection of any sensible model of political economy, it’s sort of offensive to me as an academic. And I think it’s nothing short of political malpractice that we are seeing in these states and we’ve got to emphasize that….

They are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.

Now a lot of observers have concluded the widespread rejection of the Medicaid expansion is just an extension of Republican antipathy to Obamacare, no different than the refusal to set up state exchanges. There’s some truth to that, but what I think many are missing is that conservatives are exceptionally hostile to Medicaid itself. This hostility is often disguised by support for a Medicaid block grant that would enable states to “reform” the program, but by “reform” they are often talking about eliminating the program as we know it. Best I can tell, Bobby Jindal’s “reform” proposal would place many current Medicaid beneficiaries (other than those in long-term care or with disabilities) in a high-risk pool people with pre-existing conditions. Influential conservative health care writer Avik Roy contemplates Medicaid–along with Medicare–becoming a premium support program where poor people would be given subsidies to buy private insurance.

The bottom line is that an awful lot of Republicans don’t want to expand a program they essentially want to abolish or at least radically transform, totally aside from the fiscal arithmetic or the linkage to Obamacare. It doesn’t speak well for their honesty or devotion to “conservative principles” that they hide their intentions behind bogus fiscal arguments.

I’ve often said that if I were a conservative Republican governor I’d figure out exactly how much damage HHS would let me to do traditional Medicaid and then secure a waiver allowing those “reforms” in exchange for agreeing to expansion. If anyone on the Right attacked me, I’d just respond that I had tricked the Obama administration into paying for the kind of Medicaid “reforms” conservatives had always advocated. But this appears to be too subtle a strategy for today’s Republicans. It’s easier to Just Say No.

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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.